Latin American Interdisciplinary Perspectives on Bioethics and Disabilities 3031228901, 9783031228902

Table of contents :
Foreword
Contents
Part I: Subjects with Intellectual and Psychosocial Disabilities
Chapter 1: Empathizing with the Intellectually Disabled
1.1 Introduction
1.2 Dehumanization and the Intellectually Disabled
1.3 Identification with a Point of View
1.4 Learning to Empathize with the Intellectually Disabled
1.5 Humanistic Respect and Care
1.6 Conclusion
References
Chapter 2: Experts by Experience, Demedicalization and the Emergence of Alternative Approaches to Mental Health Care: Gaining Autonomy & Medication Management (GAM) in Brazil
2.1 Introduction
2.2 Demedicalizing Discourses and Practices in the Field of Mental Health
2.3 Legitimacy of Experiential Knowledge of Users and Ex-users of Mental Health Services in Debate
2.4 The Origins of Gaining Autonomy & Medication Management (GAM) and Adaptations for the Brazilian Context: The GGAM-BR
2.5 Conclusion
References
Chapter 3: Practice, Human Flourishing and Centres for Psychosocial Attention: A MacIntyrean Analysis from Both the User’s and the Community’s Standpoints
3.1 Introduction
3.2 Centres for Psychosocial Attention
3.2.1 Psychiatric Reform
3.2.2 General Functioning
3.2.3 User, Family and Community
3.3 Practice and Human Flourishing
3.3.1 Choosing Concepts
3.3.2 Practice
3.3.3 Human Flourishing
3.4 Applying MacIntyre’s Ethical Approach to CPAs
3.4.1 Flourishing Inside the CPAs
3.4.2 Flourishing, Vulnerabilities, and Dependency
3.5 Conclusion
References
Chapter 4: The Phenomenological Model as a Basis for the Inclusion of People with Intellectual Disabilities and Psychosocial Impact
4.1 Introduction
4.2 Background
4.3 Case Presentation
4.3.1 Identification of Problems, Bioethical Principles and Values in Conflict
4.4 Deliberation
4.5 Considerations for the Application of Informed Consent
4.6 Ethical Guidelines for Community Intervention and Social Network
4.7 Aspects of Legality in the Context of Chile
References
Part II: Moral and Legal Agency
Chapter 5: Argentina’s Mental Health Law: Sociocultural Questions Regarding the Normative Framework
5.1 Introduction: Legal Norms Faced with the Imprecise Borders of Mental Illness
5.2 Madness and the Urgent Necessity for an Approach with a Gender Perspective
5.3 Toward (Biased?) Inclusion: Reflections on the Recent Argentine Legislation
5.4 Conclusion
References
Chapter 6: Legislation and Practices of Psychiatric Institutionalization in Brazil: A Foucauldian Interpretation of Barbacena’s Holocaust
6.1 Introduction
6.2 Brazilian Holocaust: Barbacena’s Genocide
6.2.1 Luizinho
6.2.2 Antônio Gomes da Silva
6.2.3 Conceição Machado
6.3 A Foucauldian Analysis: Bodies and Powers in Barbacena
6.4 A History of Brazilian Legislation Regarding the Psychiatric Institutionalization of Those Considered to Be Abnormal
6.5 Psychiatric Institutionalization in Brazil Today
6.6 Final Considerations
References
Chapter 7: Nootropics in the Era of Affective Capitalism: Drug Consumption and Discourse Effects
7.1 Introduction
7.2 Pharmacologization and Techonologies of the Self
7.2.1 The Emergence of Pharmacologization
7.3 Diagnostics in the Era of Pharmaceutical Reason – The Morality of the Circulation of Psychotropics
7.3.1 Psychotropic as Nootropic: Representations of Medication, Expectations about Performance in the Era of Affective Capitalism
7.4 Final Considerations
Bibliographic References
Chapter 8: The Body in O Cemitério dos Vivos by Lima Barreto: An Aesthetic Phenomenological Reflection on the Practice of Norms
8.1 Introduction
8.2 Narrative: Lima Barreto’s O Cemitério dos Vivos
8.3 An Interpretation of the Living Body as a Work of Art in O Cemitério dos Vivos Grounded in Merleau-Ponty
8.3.1 Between Moral and Psychiatric Norms: The Body-Subject’s Experience as a Work of Art in a Psychiatric Hospital
8.3.2 Among the Obligation, Prohibition and Permission of Moral and Psychiatric Norms: The Body-Subject Experience as a Work of Art
8.3.3 Legal Norms of the State Applied to the Afro-Descendant, Immigrant, Indigent and Insane Body-Subject
8.4 An Interpretation of O Cemitério dos Vivos Based on Emmanuel Levinas
8.4.1 The Vulnerability of the Body Between Lucidity and Madness
8.5 Conclusion
References
Chapter 9: The Rights of Children with Psychosocial Disabilities and the Prescription of Antipsychotics in Childhood
9.1 Introduction
9.2 The Disease-Centred Model and Psychopharmacological Therapy
9.3 Antipsychotics for Unruly Children
9.4 In Conclusion: The Social Model of Psychosocial Disability
References
Chapter 10: “So That in the Practice of Good Manners, She Will Find a Dignified and Happy Life”: Institutional Practices Towards Incarcerated Women (Brazil, 1930s)
10.1 Introduction
10.2 Criminology
10.3 Women’s Imprisonment in the First Decades of the Twentieth Century
10.4 The Deviant Segments in the State of Santa Catarina: Women’s Situation
10.5 Final Considerations
References

Citation preview

The International Library of Bioethics 102

Ana Paula Barbosa-Fohrmann Sandra Caponi   Editors

Latin American Interdisciplinary Perspectives on Bioethics and Disabilities

The International Library of Bioethics Founding Editors David N. Weisstub Thomasine Kimbrough Kushner

Volume 102

Series Editor Dennis R. Cooley, North Dakota State University, History, Philosophy, & Religious Studies, Fargo, ND, USA Editorial Board Members Terry Carney, Faculty of Law Building, University of Sydney, Sydney, Australia Marcus Düwell, Philosophy Faculty of Humanities, Universiteit Utrecht, Utrecht, The Netherlands Søren Holm, Centre for Social Ethics and Policy, The University of Manchester, Manchester, UK Gerrit Kimsma, Radboud UMC, Nijmegen, Gelderland, The Netherlands Daniel P. Sulmasy, Edmund D. Pellegrino Center for Clinical Bioethics, Washington, DC, USA David Augustin Hodge, National Center for Bioethics, Tuskegee University, Tuskegee, AL, USA Nora L. Jones, Center for Urban Bioethics, Temple University, Philadelphia, USA

The International Library of Bioethics  – formerly known as the International Library of Ethics, Law and the New Medicine comprises volumes with an international and interdisciplinary focus on foundational and applied issues in bioethics. With this renewal of a successful series we aim to meet the challenge of our time: how to direct biotechnology to human and other living things' ends, how to deal with changed values in the areas of religion, society, and culture, and how to formulate a new way of thinking, a new bioethics. The International Library of Bioethics focuses on the role of bioethics against the background of increasing globalization and interdependency of the world’s cultures and governments, with mutual influencing occurring throughout the world in all fields. The series will continue to focus on perennial issues of aging, mental health, preventive medicine, medical research issues, end of life, biolaw, and other areas of bioethics, whilst expanding into other current and future topics. We welcome book proposals representing the broad interest of this series’ interdisciplinary and international focus. We especially encourage proposals addressing aspects of changes in biological and medical research and clinical health care, health policy, medical and biotechnology, and other applied ethical areas involving living things, with an emphasis on those interventions and alterations that force us to re-examine foundational issues.

Ana Paula Barbosa-Fohrmann  •  Sandra Caponi Editors

Latin American Interdisciplinary Perspectives on Bioethics and Disabilities

Editors Ana Paula Barbosa-Fohrmann Department of Legal Theory Federal University of Rio de Janeiro Rio de Janeiro, Brazil

Sandra Caponi Department of Sociology and Political Science Federal University of Santa Catarina Florianópolis, Santa Catarina, Brazil

ISSN 2662-9186     ISSN 2662-9194 (electronic) The International Library of Bioethics ISBN 978-3-031-22890-2    ISBN 978-3-031-22891-9 (eBook) https://doi.org/10.1007/978-3-031-22891-9 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Disability studies are about what we are, as human beings and as beings simpliciter. To write about disabilities is to write about the condition humaine: a variety of philosophical and theoretical perspectives are needed to do justice to this complex subject. Seen from Europe, the creativity, innovativeness, and diversity of Latin American discourses on this topic are striking. The present volume, Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, edited by Ana Paula Barbosa-Fohrmann and Sandra Caponi, bears impressive witness to this. Capturing what we are is necessarily an interdisciplinary project. This volume brings together 15 authors from jurisprudence, sociology, philosophy, history, pharmacy, occupational therapy, and psychology, who develop a variety of complementary, overlapping, mutually reinforcing (and sometimes mutually irritating) perspectives in 10 chapters. There are many common grounds in disability studies – authors such as Michel Foucault, Emmanuel Lévinas, Maurice Merleau-Ponty, and Alasdair MacIntyre form points of reference on both sides of the Atlantic. A particular strength of the present volume, however, lies in the philosophical perspectives drawn from Brazil's, Argentina's, and Chile’s own debates. This is far more than just the reception of an international discourse context since thinking about disabilities always is situated in specific cultural context, including historical path dependencies and shared social experiences. The authors offer a rich selection of objects of investigation. The basic questions dealt with range from criteria for human flourishing to questions of philosophy of mind, from neuroethics to phenomenological and aesthetic approaches to intellectual and psychosocial disabilities. The legal and political investigations explore the rights of those affected and the processes of their self-organization; they ask about the dynamics of medicalization and demedicalization, about the practices of

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psychiatric institutionalization and the treatment of children with antipsychotics. Finally, they examine the sociocultural premises of legislation, as well as historical cases that shed light on the path we have already traveled and the road ahead. Faculties of Philosophy and of Law, Institute for Research in Philosophy of Law at the University of Münster Münster, Germany 

Michael Quante Thomas Gutmann

Contents

Part I Subjects with Intellectual and Psychosocial Disabilities 1

 Empathizing with the Intellectually Disabled ��������������������������������������    3 Claudia Passos-Ferreira

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Experts by Experience, Demedicalization and the Emergence of Alternative Approaches to Mental Health Care: Gaining Autonomy & Medication Management (GAM) in Brazil��������������������   17 Letícia Hummel do Amaral and Javier Ladrón de Guevara Marzal

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Practice, Human Flourishing and Centres for Psychosocial Attention: A MacIntyrean Analysis from Both the User’s and the Community’s Standpoints ��������������������������������������������������������   31 Anna Caramuru Pessoa Aubert and Arthur Cezar Alves de Melo

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The Phenomenological Model as a Basis for the Inclusion of People with Intellectual Disabilities and Psychosocial Impact��������   51 Laura Rueda Castro

Part II Moral and Legal Agency 5

Argentina’s Mental Health Law: Sociocultural Questions Regarding the Normative Framework��������������������������������������������������   61 Marisa Adriana Miranda

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Legislation and Practices of Psychiatric Institutionalization in Brazil: A Foucauldian Interpretation of Barbacena’s Holocaust��������������������������������������������������������������������������������������������������   73 Ana Paula Barbosa-Fohrmann and Anna Caramuru Pessoa Aubert

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Nootropics in the Era of Affective Capitalism: Drug Consumption and Discourse Effects������������������������������������������������������   93 Fabíola Stolf Brzozowski and Marcia da Silva Mazon

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The Body in O Cemitério dos Vivos by Lima Barreto: An Aesthetic Phenomenological Reflection on the Practice of Norms ������������������������������������������������������������������������  105 Ana Paula Barbosa-Fohrmann and Marcelo Fabri

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The Rights of Children with Psychosocial Disabilities and the Prescription of Antipsychotics in Childhood ��������������������������  125 Sandra Caponi

10 “So  That in the Practice of Good Manners, She Will Find a Dignified and Happy Life”: Institutional Practices Towards Incarcerated Women (Brazil, 1930s)��������������������������������������  139 Viviane Trindade Borges, Fernando Salla, and Carolina Wanderley Van Parys de Wit

Part I

Subjects with Intellectual and Psychosocial Disabilities

Chapter 1

Empathizing with the Intellectually Disabled Claudia Passos-Ferreira Abstract  This chapter is devoted to reflecting on the role of empathy in interactions with people with profound intellectual disabilities. We have a duty to respect people with intellectual disabilities. Respect involves identification with a point of view. We owe them an effort at identification with their perspective. However, if intellectually disabled people’s communicative abilities are impaired, our apprehension of their point of view might be limited, reducing our ability to identify with them and respect them. To answer this challenge, I appeal to empathy. Through imaginative empathy, we can learn to identify with their perspectives. I argue that empathy is a good moral guide and can be helpful in developing respectful attitudes toward people with profound intellectual disabilities. Keywords  Intellectually disabled · Identification · Respect · Care · Empathy

1.1 Introduction We have a duty to respect intellectually disabled people. We owe them a kind of respect and care that we owe to all fellow human beings  – a kind of humanistic respect. This duty might be stronger for those who care about them, including their parents, family, and caregivers. However, ultimately, any normal adult human being has a duty to treat intellectually disabled people humanely and respectfully. One major challenge arises from people with especially profound intellectual disabilities. A common view is that these people do not have a point of view with which we could identify with in order to relate to them. If having a point of view with which others can identify with is required for being morally respected, and people with profound intellectual disabilities do not have a point of view, then respect for people with profound intellectual disabilities is compromised.

C. Passos-Ferreira (*) New York University, New York, NY, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_1

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To answer this challenge, I will argue that we should distinguish different sorts of points of view. It may be that people with profound intellectual disabilities lack a reflective point of view. But a reflective point of view may not be required for identification and respect. Profoundly intellectually disabled people may still have a pre-reflective point of view, and this point of view may ground identification and respect. There remains a challenge. If intellectually disabled people’s communicative abilities are impaired, our apprehension of their point of view might be limited, reducing our ability to identify with them and respect them. To answer this challenge, I will appeal to empathy. Empathy plays a key role in enhancing our understanding of profoundly impaired people. Through imaginative empathy, we can learn to identify with their perspectives. It’s often accepted that empathy is a good guide for caring relationships. I will also argue that empathy is a good moral guide and can be helpful in developing respectful attitudes toward people with profound intellectual disabilities.

1.2 Dehumanization and the Intellectually Disabled There is no consensus about how to define intellectual disability. For my purpose here, I consider people with intellectual disabilities in functional terms as proposed by the last edition of the Diagnostic and Statistical Manual of Mental Disorders 5 TR (American Psychiatric Association (APA) 2022). According to the DSM-5-TR, intellectual disability “is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains” (APA 2022). People with intellectual disabilities vary in a large spectrum, from mild to severe and profound cognitive impairment. I will be mainly concerned here with people with severe and profound intellectual disabilities, although some of my claims might apply to mild and moderate cases too. People with profound intellectual disabilities have disabilities in conceptual, social, and practical domains, impairing their ability to adapt to and undertake everyday tasks. They have limited capacity for memory, language, and practical knowledge. They have impaired awareness of others’ thoughts and few interpersonal communicational skills. Their learning and self-management capacities are impaired. They require support for all aspects of daily life and are highly dependent on caregivers. Historically, the intellectually disabled have been the target of disrespect, abuse, and immoral treatment. Public perceptions of the intellectually disabled as ‘sick’, ‘subhuman’, ‘menace’, ‘object of pity’, ‘burden of charity’, and ‘developing individual’, have contributed to dehumanizing treatment (Keith and Keith 2013). Public policies of institutionalizing and confinement for care and treatment of individuals with intellectual disabilities have immensely contributed to disrespect and lifelong segregation (Keith and Keith 2013). It is well-known that people with disabilities suffered a process of eugenic dehumanization during the Nazi period. Under the

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Nazi regime, people with disability, in particular those with intellectual disabilities and mental illness, “were deemed to be less than fully human” and were the target of a persistent eugenic campaign “aimed at eliminating people like them” (Wilson 2021, p. 174). In Making Monsters (2021), David Livingstone Smith describes the psychology of racial dehumanization, particularly of Jews and Black people. According to Smith, dehumanizing others involves conceiving of them as subhuman creatures, belonging to inferior species, like non-human animals or supernatural creatures (monsters). However, it also involves conceiving of them as humans. The process of dehumanization involves metaphysically contradictory beliefs or representations of the other as both human and subhuman. As a consequence, Jews and Black people are seen as cognitively threatening, making people into ‘monsters’ (Smith 2021, p. 255). Eric Schwitzgebel and Amelie Green (2022) suggest that the racial dehumanization process described by Smith (2021) can be extended to the cases of cognitive disabilities. Dehumanization is also present in caregivers’ attitudes toward the intellectually disabled. Caregivers, and even family, frequently abuse, disrespect, and dehumanize the severely intellectually disabled. There is a sort of metaphysical discomfort in seeing the intellectually disabled as unnatural and threatening – they might seem “creepy, occupying a gray area that defies familiar categories, at once both human and subhuman.” Caregivers seem to attempt to resolve this conflict “by symbolically degrading their clients”, and by “implicitly asserting their clients’ sub-­ humanity” (Schwitzgebel and Green 2022). By this symbolic degradation, they can justify their sadistic abuse, their acts of purposeless cruelty, and convenient mistreatment. As Smith (2021) points out, dehumanization often facilitates abuse, violence, disrespect, atrocities, harm, and degrading behavior. Schwitzgebel and Green (2022) argue that caregivers often have dehumanizing representations. They refer to their clients as non-human animals; they refer to them using the ‘it’ pronoun – a verbal symptom of the dehumanization. At the same time, they also refer to their clients as humans with rights. As Schwitzgebel and Green point out, it is relevant to solve this metaphysical dissonance of conflicting representations, if we are concerned with the ethical treatment of the cognitive disabled. They suggest that we should develop a more capacious understanding of humanity where high levels of cognitive abilities are not essential for being or being perceived as fully human. A more inclusive notion of humanity can be a remedy against dehumanizing attitudes toward the intellectually disabled. How can we treat the intellectually disabled humanely? There have been more inclusive types of treatment that go beyond the past practices of institutionalization and isolation of the intellectually disabled from social activities. There have been legal protections and human rights protections, such as the right to receive public education with individualized educational programs, for example, the Declaration on the Rights of Mentally Retarded Persons in 1971, and the Declaration of Intellectual Disabilities in 2004, demanding basic human rights and freedom from discrimination (Keith and Keith 2013, p. 153). There has been also public awareness

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of adopting a more inclusive language. Categories and labels used to describe people affect the way we think about them. Recently, there have been attempts to avoid dehumanizing and demeaning labels historically used, such as mental retardation, mental deficiency, idiocy, or imbecile; and the introduction of less stigmatizing categories such as intellectual or cognitive disability (Keith and Keith 2013). One aspect of the dehumanization process involves regarding others as having no worth, or as being unworthy of equal moral standing or full respect as persons. One important way of humanizing the intellectually disabled is to extend to them the attitudes we have toward persons. One important attitude is showing respect to someone. Respect involves valuing an object from a moral point of view. Respect is an attitude, a way to treat and value someone. It has cognitive (beliefs, judgments, deliberations), affective (emotions, feelings), and conative dimensions (motivations, dispositions to act, and forbear from acting) (Dillon 1992, 2021). Treating someone with respect means paying attention and perceiving the person as worthy; it involves the belief that the person is worthy of attention. As Robin Dillon points out, respect involves a judgment that the object has “a feature which makes it worthy of respect”; so, respect is grounded in “those features of an object that make it worthy of attention and appropriate response” (Dillon 1992, p. 113). Respect for persons involves “recognizing that a being is a person”, and “appreciating that persons as such have intrinsic moral value”, that is, they matter morally in their own right (Dillon 1992, p.  112). In this sense, the features which make something a person are the features that make persons matter morally (Dillon 1992, p. 113). On a Kantian view, what grounds the value of a person is their capacity for rational autonomy and self-reflection. So, respect for persons involves respecting their capacity for rational autonomy.1 However, if respect is grounded wholly in persons’ rational and self-reflective capacities, this might entail excluding the profound intellectually disabled as deserving respect. The scope of the concept of a person constrains or expands the class of human beings who warrant respect. A broader conception of persons, where rational capacities are not required for being an object of respect, might yield a more respectful and humane attitude toward the intellectually disabled. In the next section, I examine a more inclusive approach to respect.

1.3 Identification with a Point of View A common idea of what constitutes respect for others is that respect involves identification with a point of view; that is, showing respect to someone requires taking into consideration the way they see and experience the world around them (Dillon  As Dillon (1992) points out, there are different ways of respecting persons, for example, respecting their moral and legal rights. I will be most concerned here with respecting in the sense of caring or having concern for others. 1

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1992; Vorhaus 2020). Persons have desires, goals, and life purposes. Respect for others involves an understanding of an individual’s life goals and purposes; it involves an understanding of what the person really wants and desires. It is through an identification with your perspective that I can understand how my actions might affect your life purposes and intentions, and what I am expected to do to cultivate a respectful relationship with you. For example, I should not unjustifiably interfere with your actions and decisions; I should give you space to exercise your rational capacities. What is to have a point of view? On one conception, this requires a conscious and autonomous individual who acts for reasons and has purposes in life; they are conscious of themselves and their situation, and the world around them. Having a point of view involves being capable of rational autonomy, the ability to act on the basis of reasons and make evaluative judgments, and to be concerned with one’s future. However, the capacities required for having this sort of rational point of view seem not to be present in some human beings, such as neonates, patients in vegetative states, and people with severe or profound intellectual disabilities. These people have no (or little) self-consciousness and self-reflection, they cannot reason about their future or make decisions, and they have reduced capacity for communication. It’s arguable that they are not capable of rational autonomy. If so, they lack a point of view as traditionally conceived. According to John Vorhaus (2020), this poses a challenge for respecting people with profound intellectual disabilities. If respect involves identification with a point of view, and a person lacks a point of view, there is no perspective with which we can relate and identify with – even if we are willing to respect them. If this is right, identification-based respect might not be possible for the profound intellectually disabled, among others individuals. If we should treat all persons with identification respect, how can we identify with the intellectually disabled who lack higher cognitive capacities? Does this mean that they have no point of view at all? An alternative proposed but not developed by Vorhaus (2020) is to ground respect in a less demanding account of what is to have a point of view. I suggest that what matters for respect of personhood is a pre-reflective point of view. On the traditional account, a point of view requires rationality, complex narratives, deep interpersonal relations, and a perspective on ourselves and the world. In this sense, having a point of view is being capable of having beliefs and representations of ourselves, others, and the world, and being aware of their continuing existence over time. This is actually the point of view of a cognitively abled adult human with the capacity for self-consciousness, self-reflection, for acting on the basis of reasons, interpersonal relations, and linguistic communication. In a broader sense, any conscious being has a point of view that is intrinsically associated with being conscious. Conscious creatures have a perspective on the world around them. Every conscious being has a minimal pre-reflective

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consciousness.2 Being conscious necessarily involves a subjective perspective, what Thomas Nagel (1974) calls what it is like to be that person. A creature is conscious if there is something that it is like to be that creature. To be a conscious creature is to be capable of undergoing experiences, such as visual or auditory sensations, or bodily sensations or emotions, or felt moods. Conscious creatures can also exhibit self-consciousness. Humans and some high-functioning non-humans animals develop self-reflective consciousness associated with higher cognitive capacities (Block 2005). As self-reflective consciousness requires higher cognitive capacities, we find different degrees of development of self-reflection during human development (Rochat and Passos-Ferreira 2008; Passos-Ferreira 2010). Those capable of self-consciousness develop a reflective point view. Among people with intellectual disabilities, reflective abilities can be limited or absent entirely. We can disentangle consciousness and self-consciousness. Having experiences is different from reflecting about those experiences. Animals are sentient creatures, but not always capable of self-consciousness. Sentience is the capacity for having subjective experience, with a positive or negative valence, such as pain or pleasure (Harnad 2016). The paradigmatic case of a mind without self-reflection is the non-­ human animal mind (Rowlands 2016). Indeed, the literature on animal consciousness and animal cognition has been very helpful in expanding our understanding of sentience, consciousness, and even our own minds. However, the comparison between non-human and human animal minds is not as straightforward as it seems, and, in the case of the intellectually disabled, it can be epistemically flawed as Eva Kittay (2005) reminds us. For our purposes of understanding the intellectually disabled mind, the comparison with sentient minds might be misleading. Having an impaired human brain that was biologically programmed to develop in a certain way might result in a very different mind than a non-human animal mind that achieves all the sentient capacities expected for their species. Although it might be possible to compare degrees of cognitive capacities across different species and generate relevant insight into the structure of their conscious experiences, each species might develop creatures with different consciousness structures, different perceptual capacities, different feelings, emotions, and reasoning. The literature on infant consciousness might be helpful here. It is widely accepted that infants are conscious at birth (Passos Ferreira unpublished-a). There is something that it’s like to be a newborn. However, infants lack certain features of adult consciousness, such as self-reflective organization and first-person introspective access to their phenomenal experience. They don’t have such a reflective point of  I am using the notion of ‘pre-reflective consciousness’ here in a very general way that can be compatible with different theories of consciousness. It’s the idea that the early stages of consciousness do not require self-reflective processes that emerge later in development. Even some versions of higher-order theories of consciousness can be compatible with the idea of a minimal conceptual structure at birth which would give neonates the capacity for pre-reflective consciousness (Gennaro 2012). 2

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view from which they can reflect on their actions, their interests, and preferences, and express concern about their future. Those features emerge at a later point in their development. However, they have a pre-reflective point of view that is directly associated with the type of capacities they are able to exercise. They have sensory capacities associated with perceptual experiences (auditory, visual, tactile, olfactory, gustatory experiences) and bodily experiences; they are capable of experiences of pain and pleasure; they are capable of feeling emotions, and using emotions to evaluate their environment as good or bad; they also have desires and motivations for actions; and they have early cognitive processes (e.g., object permanence; face recognition) (Passos-Ferreira unpublished-b). These phenomenal experiences constitute their pre-reflective point of view from where they perceive and represent the world, and act upon their environment. Parents and caregivers make a constant effort to understand infants’ experiences  – what their feelings, emotions, desires, and intentions are. They are constantly in the process of identifying with their infants’ point of view to anticipate their needs, preferences, and desires. This is a sort of a fusional state between the mother and the infant, in an attempt of the mother to understand their infant’s needs and desires (Passos-Ferreira 2010). Their point of view need not be a complex cognitive point of view. It is a pre-reflective point of view. From our knowledge of infants’ capacities and how those capacities develop and are deployed, we can infer their point of view: e.g., a desire of grasping a pacifier; crying for a physical discomfort; curiosity to play with a mobile; feeling bored by a repetitive stimulus; feeling joy seeing a familiar face, etc. By understanding their point of view, we can create a respectful developmental niche for infants (Passos-Ferreira 2010). Infants with profound intellectual disabilities are born with injured or anomalous brains. Their anomalous or injured brains develop with functional and organizational impairments that affect their pre-reflective point of view since birth. From this pre-reflective point of view, intellectually disabled infants will develop more or less some of those capacities. Those who acquire a certain capacity for communication will certainly expand this pre-reflective point of view, being capable of representing their desires and communicating their preferences with their caregivers, some will develop few representations about themselves and their caregivers. Is this pre-reflective point of view enough to warrant identification respect? Agnieszka Jaworska (2010) proposes that identification respect involves the capacity to care or have an emotional attunement to an object or event. A pre-reflective point of view might be sufficient to warrant care of this sort, as it involves sensorial and emotional states of individuals with which the observer can identify with. In my view, empathizing with others’ perspectives is crucial for our personal relationships with others but also for treating them with respect and dignity. Understanding an infant’s point of view is crucial for caring relations and also for respectful and moral treatment of them. The same is true for our relationships with people with severe and profound intellectual disabilities. The intellectually disabled face even larger limitations in communicating their inner states. Their disability drastically impairs their language acquisition and communicative skills. Even basic feelings of pain, hunger, discomfort, or thirst cannot be easily expressed and

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communicated. However, as infants, they have a pre-reflective point of view, and we can still make an effort at identification with that point of view. Understanding the potential reasons for their behaviors help us to relate with them in their particular existence, in their individuality, avoiding attributing their behaviors as simple expressions of their pathology. For example, we can identify with feelings of physical discomfort or pain, behaviors of pain avoidance, frustration in situations of perceptual deprivation; joy in listening to their preferred song; feelings of attachment.

1.4 Learning to Empathize with the Intellectually Disabled I have argued elsewhere that empathy plays a key role in contexts of caring and helping individuals who cannot express their emotions, desires, and beliefs (Passos-­ Ferreira 2015). In what follows, I argue that empathy can help to build a respectful relationship with the intellectually disabled. How can we empathize with severely and profoundly intellectually disabled people’s points of view? Empathy is an affective reaction that occurs as a response to overt perceptible cues indicative of another’s affective state or as the consequence of inferring another’s state on the basis of indirect cues (Eisenberg and Strayer 1987). It involves representing one’s feelings and perspective. There are two psychological processes: an affective one which involves sharing affective states with another person; and a cognitive one which involves simulation of the thoughts and beliefs of others. Additionally, I distinguish between perceptual empathy and imaginative empathy (Passos-Ferreira 2015). Perceptual empathy is a perceptual mechanism for understanding others’ emotions. Imaginative empathy is an imaginative or projective simulation of others’ affective perspectives. Understanding another’s points of view involves understanding their feelings and emotions, that is, identifying the type of emotion, the relationship between the emotion and a given situation, and the motivational factors triggered by the emotion (Passos-Ferreira 2015). Perceptual empathy plays a crucial role in transparent contexts, where we can overtly perceive cues that indicate another’s affective states (e.g., a person’s facial expressions or body gestures). In opaque contexts, emotions are not overtly expressed, and the motivational aspects may differ from our own motivations in similar contexts. In the absence of perceptible clues, we must rely on imaginative empathy to grasp another’s mental states. In recent work, I’ve argued that imaginative empathy is a powerful epistemic tool (Passos-Ferreira 2020). It allows the subject to understand others’ perspectives and to avoid perspectival distortions. Moreover, it can be a crucial source of information in opaque situations: situations where the information about others’ mental states is not transparent to the spectator. In these cases, the spectator has to understand the situation and infer the motivational aspects without direct perceiving affective cues. Imagination and simulation can play a central role in these cases. In the simulation process, when we attribute mental states to others, we run our own psychological mechanism offline, using features of the target person’s situations rather than our

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own as inputs. What is simulated is not an actual decision, but a hypothetical reaction to a situation. The simulation involved in the generation of, for example, a moral sentiment involves transcending our own immediate reactions: we do not just imagine how we would feel in someone else’s situation, but how we would feel in that situation were we free of the potential distortions deriving from our particular position. Imaginative empathy plays a central role in decisions about the lives of those who cannot express themselves in a transparent manner. In opaque contexts where we cannot rely exclusively on perceptive cues to decide what is the right action, we have to use our imagination and simulation abilities to grasp individuals’ internal affective perspectives to make decisions. We should exercise empathy with the intellectually disabled who suffer and are not able to express their desires and concerns. They appeal to our imaginative powers and they might want us to share their vulnerability and suffering as fellow humans. They appeal to our imaginative effort to imagine what it is like to be intellectually disabled by taking their internal perspective and communicating this imaginative effort (Coeckelbergh 2007; Passos-­ Ferreira 2015). Can imaginative empathy help us to understand others’ perspectives? There has been some skepticism against empathy as an accurate epistemic tool to take another person’s perspective. Peter Goldie (2011) has expressed some concern that imagining being others would give an accurate picture of others’ mental states. Nevertheless, others have expressed their optimism that imagining others can help us to understand them better (Maibom 2018; Kind 2021). There are two ways of imagining others. We can imagine ourselves in another’s situation, or we can imagine being another person in her situation. Imaginative empathy allows us to experience a mental state that is similar to that mental state experienced by another, but that is still related to our own psychological experience, so we can understand that experience, as the mental state plays a similar role in our psychology as it would play in another’s psychology (Maibom 2018). So, although the empathizer might not mirror all elements of the other’s mental states, their imaginative empathic effort can help to accommodate differences in their experiential perspectives. Empathically imagining others is a skill that can be enhanced. In a recent paper, Kind (2022) argues that imagination is a skill, and as such it shares features with other skilled activities: it can be done more or less well; it’s under rational control; it can be improved via practice and training. A similar argument can be applied to imaginative empathy. We can learn how to expand and improve our imaginative empathic abilities to get an accurate picture of others’ minds. Clinicians, nurses, and caregivers exercise their imaginative empathy, and with practice, they become better and better at empathically imagining their clients’ mental states and understanding their minds. I argue that imaginative empathy can play a key role in understanding and respecting the intellectually disabled. How can we imagine disabled minds? We should engage our imaginative empathic abilities in this task. Given their limited communication capacities, most of the situations with the profound intellectually disabled involve opaque contexts where there are not too many cues to infer their

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experiences and feelings. Thus, in imagining the intellectually disabled we might not be able to capture all the nuances of their perspectives, and sometimes we might fail to understand them. Although our imaginative abilities are imperfect, we owe them our efforts to understand them. There are more things to understand about the intellectually disabled than is usually assumed. Eva Kittay’s (2005) inspiring description of her daughter Sescha gives many insights into how to fill the gap in our knowledge of their minds. A severely disabled mind might have simple intentions and desires. Empathizing with them might involve two different processes. One is to identify potential similarities with our own perspective. Although mentally impaired, many disabled people’s behaviors can be reconstructed as motivated by reasons. These behaviors include avoidance behaviors, crying when feeling pain or displeasure, preferences for certain stimuli, and attachment to specific persons. Empathizing with the disabled allows us to understand their behavior as motivated by reasons and to reconstruct the potential reasons associated with their behaviors. Another process is to identify potential particularities and idiosyncrasies of their minds. Severe and profound intellectual disabilities can be associated with different neurodevelopmental causes and can be associated with different comorbidities. Some types of disabilities might generate different intellectual styles and some idiosyncratic minds. There is a tendency in caregivers’ interactions with the intellectually disabled to attribute their behaviors to salient characteristics of their persons’ illness (dispositional attributions), which favors stereotypes and stigmas (Keith and Keith 2013). Imaginative empathizing can help to avoid the tendency of attributing their behaviors to dispositions related to their deficiency. Empathic understanding can help to contextualize their behaviors as expressions of their feelings, experiences and thoughts and reactions to their caregivers and environment. If this is a capacity that can be improved and enhanced, we should train caregivers to use their imaginative empathy to expand their capacities for understanding different intellectual styles. In the case of other pathological populations, such as autism, psychosis, down syndrome, and psychopath, increasing literature describing their experiences in narratives have been helping to expand our understanding of those minds. More empathic narratives about what it is like to be intellectually disabled can contribute to fill this gap in our imagination.

1.5 Humanistic Respect and Care One remaining question is whether identification with intellectually disabled people’s points of view would result in the kind of respect we are concerned with: respect for their humanity. Non-human animals, at least those who are sentient, also have a pre-reflective point of view with which we can also empathize. We can use similar empathic tools to enhance our understanding of non-human animals’ minds and their points of view. The literature on animal welfare is full of examples of how

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our empathic understanding of non-human animals’ perspectives can help us to improve their wellbeing and how we have been empathically changing our relations with non-human animals (Browning 2020). Similar epistemic tools can be deployed in the intellectually disabled case and also in the non-human animal case. But if we treat intellectually disabled people the same way we treat non-human animals, the intellectually disabled would not get humanistic respect that would work as a remedy against dehumanization. How can we develop an attitude of respect for the intellectually disabled that enhances their humanity and avoid dehumanizing treatment? An account of identification-based respect grounded on reflective points of view faces a dilemma. On the first horn of the dilemma, what is required for identification-­ based respect will not apply to all human beings; only persons with rational capacities and a point of view should be respected. If so, not all human beings will have a moral status that demands respect, and this will likely exclude the profoundly intellectually disabled who lack a point of view to identify with. Some philosophers have defended views with similar implications. Peter Singer (1975) and Jeff McMahan (2009) David DeGrazia (1996) have defended the view that high cognitive capacities, such as rational autonomy, self-consciousness and acting for reasons, are required for moral personhood and for deserving respect for persons. Those who fall below the threshold of those capacities, including the intellectually disabled, non-human animals, fetus and neonates, should be treated ethically equivalently. The intention is to avoid grounding moral standing in speciesist features that would give special consideration to human beings and human life. On the second horn, what is required for identification respect is a capacity which all humans, including people with profound intellectual disabilities, seem to have, and many high functioning non-human animals seem to have too. If so, all humans but also non-human animals have a moral status that demands respect. It follows that respect will not be an attitude owed exclusively to all and only members of the human species. This idea avoids a speciesist view of moral status, but it cannot explain why it should be disrespectful or repugnant to treat the profound intellectually disabled the same way that we treat non-human animals. To avoid this dilemma, we may suggest that identification respect is an attitude we owe only to human beings; it is species-related. Kieran Setiya (2018) proposes a humanistic account of respect, in which the scope of those who deserve humanistic respect is all human beings. He defines his humanistic view as “We have reason to care about human beings that we do not have to care about other animals; human beings have rights against us that other animals lack.” (Setiya 2018, p. 457). The correct way to interpret this view is that “rational human beings, in particular, have reason to care about other human beings”, and “the distinctive worth of humans as such is a value they have for us” (Setiya 2018, p. 465). In a humanistic approach, we should develop an account of identification respect that would confer to all human beings a moral status that demands respect. As Setiya (2018) argues, attempts to ground the concept of persons in cognitive abilities have always failed. If what makes it worth respecting a person is their cognitive abilities, that is, if respect is grounded in our cognitive abilities, those who have impaired cognition will be necessarily out of the scope of deserving respect. It

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seems that any attempt to avoid a speciesist account of respect will result in a disrespectful attitude toward the intellectually disabled. Setiya (2018) calls attention to two kinds of respect proposed by Stephen Darwall (1977): appraisal respect, which involves a positive appraisal of persons or the traits of persons that manifest their excellence; and recognition respect, which involves giving appropriate recognition or consideration to something in deciding how to act. As Dillon suggests, recognition respect is close to the idea of identification respect (Dillon 1992, p. 111). On my view, the reason severely intellectually disabled people deserve identification respect is grounded in their humanity. To avoid dehumanization, this respect is not wholly grounded in their point of view, which may be shared with non-human animals. Nevertheless, we have the ability to identify with their point of view, and our ability to treat them with identification respect is partly grounded in this ability. Who is required to make an effort at identification with one’s point of view? According to Vorhaus (2020), identification respect is an agent-relative obligation – not everyone is required to make an effort at identification, only those in specific interpersonal relations with the intellectually disabled or their family. I disagree. I would say that everyone who interacts with intellectually disabled people has the duty to display attitudes of recognition and respect; that is, attitudes of respect for them belonging to our humanity. This duty might come in degrees and it is higher for those in direct contact with disabled people. But the duty to respect the intellectually disabled applies to everyone. If just closer agents had this duty, this would imply that the intellectually disabled are valuable and worthy of respect just for their loved ones and caregivers. The intellectually disabled should have value in their own right, independent of other people’s interests, desires, and preferences. Maybe the caregivers have the duty to care for and understand them; maybe others in a distant relationship have the duty to avoid harm, and abuse. Or mistreat them. In my view, any attitude that dehumanizes a human being, including disabled people, is violating our duty to treat them with recognition respect. This is a duty that we do not owe to non-human beings (e.g., non-human animals, machines, etc.) Some humans identify so much with their pets that they treat them with a kind of recognition respect. We might praise this behavior, but this is a supererogatory attitude. We don’t have a duty to treat non-human animals as part of our humanity. We have a duty to respect non-human animals’ well-being and interests. However, all human beings should be treated as part of our humanity. So, every human has the duty to treat intellectually disabled people humanly and avoid their dehumanization. And give their unfortunate condition, we should treat them with compassion, making their lives as comfortable and fulfilling as we can.

1.6 Conclusion As a final note, I want to address a limitation in our relationship with people with profound intellectual disabilities. Although we are certainly capable of developing a respectful relationship with them, a relationship with mutual concern might not be

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possible. Mutual concern involves what Christopher Peacocke (2014) calls interpersonal self-consciousness. Interpersonal self-consciousness is a particular form of awareness in which one is aware of oneself in another person’s consciousness. Mutual concern is grounded in the way I represent myself under the gaze of others. In most cases of profound intellectual disabilities, this capacity is impaired or not developed at all. This means that we can have feelings of concern, compassion and sympathy, but relations that involve mutual concern might be impaired. Although there are constraints on the types of interpersonal relationships we can develop with the profound intellectually disabled, it is our moral duty to develop respectful relationships with them and to refrain from any dehumanizing attitude toward them. We can do this via empathic identification with their points of view.

References American Psychiatric Association. 2022. Diagnostic and statistical manual of mental disorders (5th ed. Text revised). Washington: American Psychiatric Association Publishing 2022. Block, Ned. 2005. Consciousness, philosophical issues about. In Encyclopedia of cognitive science, ed. L. Nadel, 1–11. Hoboken: Wiley. Browning, Heather. 2020. If I could talk to the animals: Measuring subjective animal welfare. Ph.D. thesis, Australian National University. Coeckelbergh, Mark. 2007. Who needs empathy? A response to Goldie’s arguments against empathy and suggestions for an account of mutual perspective-shifting in contexts of help and care. Ethics and Education 2 (1): 61–72. Darwall, Stephen. 1977. Two kinds of respect. Ethics 88: 36–49. DeGrazia, David. 1996. Taking animals seriously: Mental life and moral status. Cambridge/New York: Cambridge University Press. Dillon, Robin S. 1992. Respect and care: Toward moral integration. Canadian Journal of Philosophy 22 (1): 105–132. ———. 2021. Respect. The Stanford encyclopedia of philosophy Summer 2021 Edition, ed. Edward N.  Zalta. https://plato.stanford.edu/archives/sum2021/entries/respect/. Accessed 09 June 2022. Eisenberg, Nancy, and Janet Strayer. 1987. Critical issues in the study of empathy. In Empathy and its development, ed. Nancy Eisenberg and Janet Strayer, 3–13. Cambridge, New  York: Cambridge University Press. Gennaro, Rocco J. 2012. The consciousness paradox: Consciousness, concepts, and higher-order thoughts. Cambridge: Bradford Books. Goldie, Peter. 2011. Anti-empathy. In Empathy: Philosophical and psychological perspectives, ed. Peter Goldie and Amy Coplan, 302–317. Oxford: Oxford University Press. Harnad, Stevan. 2016. Animal sentience: The other-minds problem. Animal Sentience 2016: 001. Jaworska, Agnieszka. 2010. Caring and full moral standing redux. In Cognitive disability and its challenge to moral philosophy, ed. Eva Feder Kittay and Licia Carlson, 369–392. Oxford: Wiley-Blackwell. Keith, Heather, and Kenneth D. Keith. 2013. Intellectual disability: Ethics, dehumanization, and a new moral community. Sussex: John Wiley & Sons, Incorporated. Kind, Amy. 2021. Bridging the divide: Imagining across experiential perspectives. In Epistemic uses of imagination, ed. Christopher Badura and Amy Kind, 237–259. New York: Routledge. ———. 2022. Learning to imagine. British Journal of Aesthetics 62 (1): 33–48. Kittay, Eva. 2005. At the margins of moral personhood. Ethics 116 (1): 100–131. Maibom, Heidi. 2018. Imagining being someone else. Blog post on The Junkyard. https://junkyardofthemind.com/blog/2018/1/29/imagining-­being-­someone-­else. Accessed 7 Apr 2022.

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McMahan, Jeff. 2009. Radical cognitive limitation. In Disability and disadvantage, ed. Kimberley Brownlee and Adam Cureton, 240–259. Oxford: Oxford University Press. Nagel, T. 1974. What is it like to be a bat? Philosophical Review 83 (04): 435–450. Passos-Ferreira, Claudia. 2010. O desenvolvimento da autoconsciência em bebês. In Nascimento: Antes e Depois – Cuidados em Rede, org. Silva Maria Abu-Jamra Zornig and Regina Orth de Aragão, 133–144. Curitiba: Honoris Causa. ———. 2015. In defense of empathy: A response to Prinz. Abstracta 8 (2): 31–51. ———. 2020. L’imagination et l’agir moral. In L’Imagination. Actes du 37e Congrès de l’ASPLF (Rio de Janeiro, 26–31 mars 2018), éd. Jean-Yves Beziau and Daniel Schulthess, 583–600. Londres: College Publications. Academia Brasileira de Filosofia, vol. 1. ———. unpublished-a. Are infants conscious? https://philpapers.org/rec/PASAIC. ———. unpublished-b. The varieties of infant experience. https://philpapers.org/rec/PASTVO. Peacocke, Christopher. 2014. The mirror of the world: Subjects, consciousness, and self-­ consciousness. Oxford: Oxford University Press. Rochat, Philippe, and Claudia Passos-Ferreira. 2008. From imitation to reciprocation and mutual recognition. In Mirror neuron systems: The role of mirroring processes in social cognition, ed. Jaime A. Pineda, 191–212. New York: Springer Science, Humana Press. Rowlands, Mark. 2016. Are animals persons? Animal Sentience 10 (1): 1–18. Schwitzgebel, Eric, and Green, Amelie. 2022. Dehumanizing the cognitively disabled: Commenting on Smith’s Making Monsters. Blog post on The Splintered Mind. https://schwitzsplinters. blogspot.com/2022/04/new-­essay-­in-­draft-­dehumanizing.html. Accessed 7 Apr 2022. Setiya, Kieran. 2018. Humanism. Journal of the American Philosophical Association 4 (4): 452–470. Singer, Peter. 1975. Animal liberation. New York: Random House. Smith, David Livingstone. 2021. Making monsters: The uncanny power of dehumanization. Cambridge: Harvard University Press. Vorhaus, John. 2020. Respect, identification, and profound cognitive impairment. In The Oxford handbook of philosophy and disability, ed. Adam Cureton and David T.  Wasserman, 1–19. New York: Oxford University Press. Wilson, Robert. 2021. Dehumanization, disability and eugenics. In The Routledge handbook of dehumanization, ed. Maria Kronfeldner, 173–186. London: Routledge.

Chapter 2

Experts by Experience, Demedicalization and the Emergence of Alternative Approaches to Mental Health Care: Gaining Autonomy & Medication Management (GAM) in Brazil Letícia Hummel do Amaral and Javier Ladrón de Guevara Marzal

Abstract This chapter addresses an alternative mental health care strategy to the hegemonic medicalizing logic: Gaining Autonomy & Medication Management (GAM) (Originally, in French: La Gestion autonome de la medication. In English, the name was changed to be adapted to the acronym GAM.). Developed in Canada in 1993 following the wishes of users and ex-users of mental health services, it is characterised by the appreciation of their experiences and knowledge, usually neglected in psychiatric clinical practice, especially with regard to their drug treatments. This approach was introduced in Brazil almost 20 years later through a partnership between Brazilian and Canadian researchers. The principles were maintained but Brazilian GAM has undergone important transformations, aimed at adapting to the new context. We seek to explore the differences between the Canadian and Brazilian GAM guides, with an emphasis on the specificities of GAM application in the Psychosocial Care Network (RAPS). This focuses on providing qualified information about psychiatric drugs to users, critical reflection on their rights in health services and the participatory establishment of an action plan, aimed at promoting their autonomy and improving their quality of life. Finally, in spite of advances following Brazilian Psychiatric Reform and the emergence of initiatives such as the GAM in Brazil, we question the limits of the debate on demedicalization in the current Brazilian context. This book chapter was accomplished within the framework of the Capes-Cofecub international agreement between the Federal University of Santa Catarina (UFSC) and the University of Paris 8/ Vincennes- Saint Denis. Capes-Cofecub Project: Capes process number. 88881.191755/2018-01/ Cofecub process number Sh 940/19. It is also a partial result of Letícia H. do Amaral’s doctoral research in Sociology at UFSC and financed by FUMDES – Fund to support the maintenance and development of Higher Education, Government of the state of Santa Catarina/ Brazil. L. H. do Amaral (*) · J. L. de Guevara Marzal Federal University of Santa Catarina, Florianópolis, Brazil © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_2

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Keywords  Demedicalizing strategies · Gaining Autonomy & Medication Management (GAM) · Iatrogenic harm · Psychiatric drugs · Experts by experience · Informed consent

2.1 Introduction In recent decades, we have witnessed the emergence of alternative proposals, both in epistemological approaches and in care practices in the field of mental health. These might be understood as de-medicalizing, since they reject, to some extent, the theses of traditional hegemonic psychiatry on the causes and manifestations of psychic suffering, as well as the treatments usually given by doctors/psychiatrists to those who experience such episodes. In this chapter, we discuss Gaining Autonomy & Medication Management (GAM), a care strategy developed in Canada in 1993 which has its roots in the wishes of users and ex-users of mental health services, especially those who regularly use psychotropic drugs. It was implemented in Brazil almost 20 years later, after research that sought to understand the specifics of the local context, adapt the guide to a new reality and, thus, test its effects on the individuals involved in the treatments. This process culminated in the creation of the Brazilian GAM guide (Onocko-Campos et al. 2012a, b) and in the dissemination of this strategy among the services of the Psychosocial Care Network (RAPS) of the Unified Health System (SUS), in various regions of the country. Despite the differences between Canadian and Brazilian GAM, it is worth noting the centrality of three aspects: the respect and appreciation given to the voice and knowledge of users and former users of mental health services; the meanings attributed to users’ experiences of suffering and/or madness, and the decisions about treatments which lead to tension in the knowledge-power relations between the psychiatrist and the so-called patient.

2.2 Demedicalizing Discourses and Practices in the Field of Mental Health The processes of medicalization of life have attracted the attention of scholars since the 1960s, when the term first appeared in the context of sociology of health.1 In short, they redefine the expression of problems from the most diverse aspects of life

 Talcott Parsons (1961) was the first sociologist to use the term although his approach was functionalist and focused on the role of the ‘sick’ and the doctor, a distinctly different position to that of the works of critical perspective that came some years later like those of M. Foucault, I. Illich, and particularly amongst classic Antipsychiatry authors: D. Rosenham; R. D. Laing, D. Cooper, T. S. Szasz, E. Goffman, as well as F. Basaglia e E. Venturini. 1

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in medical terms, which are described in medical language, understood through medical rationality, and treated using medical interventions (Conrad 2007). Medicalization results from a conception of medical science that views the health-­ disease process as centred on the individual, privileging an organicist biological approach to the detriment of social, political and cultural constraints. Illich (1975) gains prominence in this debate for his introduction of the notion of iatrogenesis – iatros (doctor) and genesis (origin) – to address the harm caused by institutionalized Western medicine. Clinical iatrogenesis refers to diseases caused by health care itself, such as the side effects of medication, unnecessary surgical interventions or the production of psychological trauma. Social iatrogenesis is related to the unwanted social effects of the impacts of medicine, in particular, the growing dependence of the population on medical prescriptions and social control through diagnosis, resulting from the medicalization of social categories. Structural/ cultural iatrogenesis denotes the process through which medicine subsumes intimate and personal meaning from suffering, transforming it into a technical issue. In this case, the problem results from the destruction of people’s cultural potential to autonomously deal with illness, pain or death. (Gaudenzi and Ortega 2012). In contemporary Brazil, Amarante and Freitas (2015) and Caponi (2019) highlight the iatrogenic results of psychiatric practices throughout history, many of which are now considered methods of torture and violation of human rights (such as the straitjacket, lobotomy and electroshock). We emphasize the criticisms by users of mental health services in relation to the suffering caused by the use of psychotropic drugs, prescriptions of which have increased significantly, including in Brazilian territory,2 since their accidental discovery in the 1950s. Thus, psychiatric iatrogenesis also manifests as complications of drug treatments. These are the so-called side effects, usually not mentioned to patients in clinical practice, such as: tardive dyskinesia (involuntary spasms in parts of the face) and tremors, cardiac, metabolic (significant weight gain/loss) and sexual life (anorgasmia and decreased libido), in addition to direct intoxication,3 debilitating

 Recent data (2020), obtained by the R7 news agency from the National Health Surveillance Agency (Anvisa), point to a considerable increase in the consumption of psychostimulant substances, such as methylphenidate (Ritalin/Concerta) and lisdexamfetamine (Venvanse). Regarding the first, the consumption of boxes per year jumped from 1,343,545 in 2011 to 2,240,873 in 2019, while the second, which is more recent on the market, went from 11,065 boxes in 2011 to 616,325  in 2019. Of note is that these are the most commonly prescribed medications for preschoolers and schoolchildren diagnosed with attention deficit hyperactivity disorder. Source: https://noticias.r7.com/saude/venda-de-remedios-derivados-de-anfetamina-bate-recordeno-brasil-24102020 3  Serotonin syndrome (SS) was described in the 1970s in patients who ingested high doses of tryptophan and, later, it was also recognized in those using tricyclic antidepressants and MAO inhibitors in combination. It is currently common in patients taking selective serotonin re-uptake inhibitor (SSRI) antidepressants, psychotropic drugs prescribed to treat depression, panic disorder and obsessive-compulsive disorder, and also in derivatives used to treat migraine (sumatriptan). Source: http://www.polbr.med.br/ano02/artigo1002.php# 2

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withdrawal symptoms,4 and problems resulting from drug interactions (many psychiatrists are adept at polypharmacy). Affective and behavioural disorders associated with the regular consumption of psychotropic drugs are also addressed. Current classification systems in psychiatry fail to consider the iatrogenic components of psychopathology related to behavioral toxicity. Affective disturbances caused by medical drugs, as well as paradoxical effects, manifestations of tolerance (loss of clinical effect, resistance), withdrawal and post-withdrawal disorders, are increasingly common due to the widespread use of psychotropic drugs in the general population. Such neglect is serious, since manifestations of behavioral toxicity are unlikely to respond to standard psychiatric treatments and may be responsible for the wide spectrum of disturbances subsumed under the generic rubric of treatment resistance. The term “iatrogenic comorbidity” refers to the unfavorable modifications in the course, characteristics, and responsiveness to treatment of an illness that may be related to previously administered therapies. Such modifications may also lead to a serial development of multiple medical and psychiatric complications (cascade iatrogenesis). (Fava and Rafanelli 2019, p. 137)

It is a particularly serious matter that problems caused by prescribed drugs are usually understood by psychiatrists as resistant symptoms of the original disease or identified as the emergence of other pathologies, which can lead to the addition of new drugs in the treatment (Guy et al. 2020). The processes of medicalization of life have been extensively analysed in their various facets and consequences. Nonetheless, Gaudenzzi and Ortega (2012) emphasize the importance of carrying out studies on demedicalization, that is, on the movements of resistance to medicalization. They also propose the medicalization position of the authors Illich and Foucault as a key tool for such studies: Although Illich emphasizes the oppressive side of Western medicalized culture, his study – since it is intended to offer instruments to consider the reestablishment of an ethical-­ political balance between autonomous and heteronomous health actions – permits analysis of the growing emergence of protest movements against medicalization, which Foucault, in a more explicit and detailed way, presented through his vision of power and governmentality, in which the possibility of inventing forms of resistance from the struggles around subjectivity was an ever-present reality. (Gaudenzi and Ortega 2012, p. 27).

Following the Foucauldian line of thought, it is clear that, in the late 70s and early 80s, there was a shift in thematic concern from the study of power in the West – sovereignty, disciplinary power, biopower, and the techniques of the governance of populations – to the practices of the self: the knowledge and care of the self. In this sense, he moved from an analysis of the governance of others to focus on the governance of the self, from a concern with the political subject to the possibility of an ethical subject (Foucault 2004). It follows that the ethics of caring for the self can be understood as the production, by individuals and collectives, of practices of freedom that arise as a possibility of resistance to subjectivation processes in any of these modalities of power relations. It is in the theoretical framework of Foucault and Illich, of the potential to  In England (Guy et  al. 2020), recent research indicates approximately 40–50% in the case of antidepressants, for example. Generally, however, in clinical practice, it is claimed that withdrawal effects are mild to moderate, self-limiting and short-lived. 4

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exercise freedom and a more autonomous self-production of life, that this chapter is set.

2.3 Legitimacy of Experiential Knowledge of Users and Ex-users of Mental Health Services in Debate There is currently an intense epistemological conflict in the field of mental health between different areas of knowledge, especially between the statements and practices of psychiatry with a biological bias (hegemonic biomedical model) on the one hand, and theorists of collective health, sociology, psychology and psychoanalysis, in addition to the so-called ‘critical psychiatry’,5 on the other. It is understood that, in these conflicts, disputes arise over the meanings of madness, suffering or psychic illness, their causality and manifestations, and over proposals involving therapeutic choices that are often divergent from care models. One cannot forget, in the light of Foucault, that knowledge, which is usually considered lay, originates in the subjects themselves who experience psychic suffering and whom we will designate, as Rose does (2019): experts by experience. These are users and ex-users of mental health systems who have been demanding space and a voice in discussions on this topic. They propose a greater role in the qualification of lived experiences, participation in public policy decisions, as well as in the therapeutic options that are defined for them. The debate on medicalization-­ demedicalization in the context of mental health necessarily involves understanding the existence of games of truth that have historically legitimized certain types of knowledge while silencing others (Foucault 1976, 2006). Emphasis is given here to the hierarchical and often oppressive relationship between the psychiatrist (holder of rational knowledge) and his patient (crazy and devoid of reason), whose stigma of being alienated from his own experience prevents him from speaking for himself, from subjectively constructing a more autonomous narrative for his history, thus finding other meanings that are significant for his experiences beyond the psychiatric diagnosis, that is, the explanations based on brain disorders and genetic inheritance. It is important to return to Foucault, in the preface to the History of Madness (1976): As for a common language, there is no such thing; there is no such thing any longer; the constitution of madness as a mental illness, at the end of the eighteenth century, affords the evidence of a broken dialogue, posits the separation as already affected, and thrusts into oblivion all those stammered, imperfect words without fixed syntax in which the exchange between madness and reason was made. The language of psychiatry, which is the monologue of reason about madness, has been stablished only on the basis of such a “break in the dialogue.” (Foucault 1976, p. 52)

 Examples include Joanna Montcrieff in England, Allen Frances in the United States, as well as Paulo Amarante, Octavio Serpa Jr., Rossano Cabral Lima e Deivisson Santos in Brazil. 5

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Historically silenced by psychiatric knowledge-power, when not locked up, drugged and subjected to ultra-invasive treatments, many users and ex-users of mental health systems have sought alternative models of understanding their experiences of psychic suffering, which often oppose and challenge the knowledge and practices of hegemonic traditional psychiatry. It is clear that GAM is a proposal for mental health care, to some extent contrary to the medicalizing logic. It seeks to remove the centrality of illness and psychotropic drugs (although not necessarily completely rejecting them) and to focus instead on the users’ experiential knowledge, valuing their subjectivity and the uniqueness of their life stories. Such a strategy can be understood, in the light of Foucault, as the practice of freedom, as it resists the hierarchical relationship of power between legitimized knowledge and subjected knowledge in the field of mental health. Until now, major research in psychiatry has focused its references on those who are usually considered to be experts: medical specialists, scientific researchers, policymakers and academics. And what about the voices of users of mental health services, survivors of compulsory hospitalizations, involuntary treatments or long-term medications, that is, subjects supposedly ‘treated’ by psychiatrists? Would they not be in a better position to judge the benefits of psychiatry? (Rose 2019). Rose (2019) points out that the most fundamental observation to be made in the history of psychiatry is the persistence of the monologue of reason on madness, arguing: But it is well past time to turn to the other direction. Psychiatry and the associated psy professions all stake their claim to legitimacy not merely on their objectivity; but also because they are committed to help and not to harm those whom they analyse, diagnose and treat. Surely then, at a minimum, those to whom they minister gain the right to speak, to give their own views on the treatment meted out to them. (Rose 2019, p. 151)

This has been the premise of the initiatives we call demedicalizing agents that have emerged in recent decades, especially in countries of the global north, such as Canada, the Netherlands, Finland and the USA.6 Increasingly, critical authors in the field highlight the importance of considering the voice, experience and knowledge of users of mental health services about the treatments they receive.

 Examples of demedicalizing care strategies: Open Dialogue, Hearing Voices Movement, GAM, as well as some peer-to-peer support groups for psychiatric drugs withdrawal, such as SurvivingAntidepressants/ The Inner Compass Initiative. 6

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2.4 The Origins of Gaining Autonomy & Medication Management (GAM) and Adaptations for the Brazilian Context: The GGAM-BR Gaining Autonomy & Medication Management (GAM) as an alternative mental health care strategy was developed in the 1990s in Quebec (Canada) and since then, has been adapted and implemented in other countries, such as Brazil, Spain and Japan, with the aim of responding to some fundamental problems. The first is indiscriminate prescription and use of psychotropic drugs in addition to a considerable increase in their consumption, both in terms of quantity and duration. The second aspect is limited empowerment (little information, participation and negotiation capacity) of the users of mental health services in decisions about their treatment, with the typical centralization of power in health professionals (Onocko-Campos et al., 2012a, b; Santos, 2014). GAM emerged in the context of the mental health recovery movement of the 1970s in Anglo-Saxon countries, initiated by people diagnosed with schizophrenia, arguing for acknowledgement that individuals could not be reduced to diagnoses of mental disorders. The recovery movement understands that the disease is just one of the spheres of human life and makes room for recovery/reestablishment and the possibility of living with the illness, not necessarily the total remission of symptoms. Recovery is a dynamic, non-linear process, and has, as possible spaces for its development, mutual aid groups, civil rights and user appreciation movements. (Santos et al. 2020, p. 171)

In Canada, the initial motivation for the creation of the GAM came from a demand from users of the network of alternative mental health services,7 with a community base and a psychosocial approach, who complained about the lack of information about the medications prescribed to them, the harmful and undesirable effects related to the use and withdrawal of psychotropic drugs, continued suffering despite the drug treatment, and the expressed desire of many users to live without medication (Santos et al. 2020). According to the Canadian guide (RRASMQ, AGIDD-SMQ and ÉRASME 2019), GAM is based on the following principles: a broad, non-reductionist understanding of subjects and experiences of psychological distress beyond the disease, requiring multiple responses; recognition of users as specialists in their experiences with medications; understanding that psychiatric drugs differ in symbolic terms among users and assume different meanings; respecting users’ rights to access information about their treatment, consenting to care, obtaining assistance and participating in decisions about their treatment; and also, in the understanding that ‘satisfactory quality of life’ is a personal parameter, specific to individuals. In this  Le regroupement des ressources alternatives en santé mentale du Québec (RRASMQ). Other institutions involved in Canadian GAM: Association des groupes d’intervention en défense des droits en santé mentale du Québec (AGIDD-SMQ) and Équipe de recherche et d’action en santé mentale et culture (ÉRASME) (FRQSC). Available at: http://www.rrasmq.com/, http://www. agidd.org/, https://erasme.ca/. GAM received funding from the Canadian Ministry of Health and Social Assistance. 7

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sense, the GAM aims to empower users of psychotropic drugs through reflection and an action plan, to face problems related to medication, health and their social-­ relational contexts, and its ultimate objective is to improve quality of life. The proposal also values the participation of other actors, such as spouse/family/friends, health professionals and community organizations that can act as a support network, providing assistance and information throughout the process. The first GAM personal guide8 was created in 2001 following long discussions between users and technicians, and was aimed at those diagnosed with severe mental disorders. It is remarkably self-reflective material and is divided into seven steps: (1) ‘Awakening’, which addresses the rights of users of mental health services, especially with regard to medications; (2) ‘Observing and Reflecting’, when the user is invited to make an analysis of their own life, their relationship with medications, with the aim of making changes towards a better quality of life and well-being; (3) ‘Find the right people, information and tools’, in which the subject is guided to find reliable information about medications, define a support network and strategies to deal with difficult moments; (4) ‘Deciding’, when the subject is faced with the decision to continue, reduce or interrupt a particular medication; (5) ‘Planning and preparing for change’, which focuses on the importance of establishing an action plan and addresses the negotiation with the prescribing psychiatrist/doctor, informing the user of the withdrawal process and its typical effects on the body and emotions so that, as a person with rights, they know in advance of the possible obstacles and challenges on the journey and have alternative strategies to deal with suffering; (6) ‘A method to reduce or stop medication and lessen withdrawal reactions’, when the user is warned about the potential difficulty in discontinuing psychiatric medication and offered, if the individual so wishes, a method of gradual and progressive reduction that makes the process more tolerable; (7) ‘Managing withdrawal reactions and emotions’, when the main reactions felt in the withdrawal process of any class of psychotropic drugs are presented, namely: anxiety, nervousness, agitation, sleep problems, need to rest and sleep more, irritability and fatigue. Next, a long list of known physical and psychological reactions, legitimized by users’ experience, is presented for each specific class of psychotropic – antidepressants, antipsychotics, tranquilizers, stimulants, mood stabilizers. Finally, tips are provided on how to manage intense feelings and sensations, explaining that when psychiatric drugs are ingested, many emotions (anger, fear, sadness) become dormant and that, therefore, when experiencing the withdrawal process, it is common and understandable that such emotions and feelings resurface (RRASMQ, AGIDD-SMQ and ÉRASME 2019). It is important to note that, even in the original GAM, there is no incentive to discontinue drug treatment. This is a personal decision of the user, who, if they so wish, will have access through the guide to qualified information on the most common withdrawal symptoms, as well as tools to deal with the challenges arising from

 In French, entitled Gestion autonome de la médication de l’âme: mon guide personnel (2001).

8

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the reduction/withdrawal process. Furthermore, it is expressly recommended that the user never do so without the supervision of a doctor. It should be noted that informed consent is the current flag raised by those who feel harmed by mental health systems and by the consumption of psychotropic drugs. It is understood that without qualified and honest information, there is no possibility of choice. It is therefore necessary to recognize a fact: psychiatric medications can cause a variety of harm, including chemical dependence that results in withdrawal symptoms, frequently severe and debilitating, for most of those who try to reduce or stop their use (Guy et al., 2020). The list of unpleasant and disturbing sensations and feelings is extensive, and it is described in the Canadian guide. It is important to highlight, in this debate, the book The myth of the chemical cure: a Critique of Psychiatric Drug Treatment (Montcrieff 2008). In summary, Montcrieff advocates a shift in clinical practice away from a disease-centred model to a drug-centred model. In other words, she argues for abandoning the false explanations, usually provided to those who arrive at a mental health service with complaints of psychological distress, about the existence of a brain chemical imbalance, an explanation that is not scientifically proven (Rose 2019) and therefore a myth. Instead, she proposes that psychiatrists take a more honest/credible position and provide their patients with correct information about the action of psychotropic drugs on the brain. Instead of maintaining that they are necessary to correct a supposed brain imbalance (serotonin deficit, for example) underlying the diseases, she proposes that the medical profession recognize the real functioning of drugs which is to induce a state of altered brain function. The drugs frequently act to reduce certain symptoms and bring some benefit since they mask emotions and change undesirable behaviours, but they will never cure pathology. Only this paradigm shift would enable a more honest and ethical practice with psychiatric patients, who would consequently feel truly free to choose the treatment offered and consent to it or not. In Brazil, GAM resulted from an international partnership between researchers from UNICAMP, UFRJ, UFF, UFRGS and the Canadian GAM project, linked to the University of Montreal. The Brazilian Psychiatric Reform culminated in the establishment of a new mental health policy based on the community-based psychosocial care model in 2001. In accordance with this reform,9 the implementation of GAM involved a robust research-action project. As in Canada, users, researchers and mental health workers from selected Psychosocial Care Centres (CAPS) gathered, aiming to understand local specificities and adapt the strategy to the Brazilian context.10 Based on the results of this initial multicentric research (Onocko-Campos et al. 2012b) conducted during 2009 and 2010, the GGAM-BR: A Guide to Shared

 Valorization of democracy, care in liberty, participation, citizenship, user autonomy for users of mental health services. 10  The chosen strategy was to establish four interventions (GI) that lasted 10  months in Rio de Janeiro (RJ), Campinas (SP), Novo Hamburgo (RS) and at the State University of Campinas (Unicamp-SP). 9

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Care for Psychiatric Medication11 began to take form and was completed in 2013. There are differences between the Canadian and Brazilian initiatives that should be highlighted. The first is the exclusion, from the GGAM-BR (Onocko-Campos et al. 2012a), of the second part of the original guide that related to withdrawal of psychiatric drugs.12 Researchers claim that, differently from the Canadian context, CAPS users (n = 30) did not express the desire to discontinue medication. On the contrary, as users of the Unified Health System (SUS) and the Psychosocial Care Network (RAPS), they asked for the guarantee of free access to drugs, in addition to expressing the desire for more dialogue in the relationship with professionals (Onocko-Campos et  al. 2012a, b; Santos 2014). Therefore, the Brazilian guide does not work with the proposal of withdrawal/ reduction of medications. The focus is on providing the conditions for the user to achieve greater autonomy in the co-management of their treatment, which may include but not be limited to the consumption of psychotropic drugs which are considered an important part of an individual and multidisciplinary therapeutic project. Santos (2014) thus states that the Brazilian GAM experience would be better defined as Shared Medication Management. More recently, Palombini and Del Barrio (2021) argue that, in fact, there was no adaptation of the Canadian guide for the Brazilian reality, but rather a complete transformation. According to Surjus (2019), key researchers in the field deliberated over the translation into Portuguese of the second part of the guide, referring to the withdrawal/reduction of medications. A planned review of the GGAM-BR, including the issues mentioned previously did not take place due to lack of funding. In addition to the aforementioned argument regarding the lack of desire of CAPS users to withdraw medications,13 it is argued that: Considering the scenario of mental health policy in the country, whose reformist project, despite its advances, did not prevent pharmacological treatment from occupying a central and often exclusive place among therapeutic offers, the scholars determined that the research would become unfeasible in the service network if the proposal of the original Guide was maintained in its entirety. There was also fear on the part of research psychiatrists, that the Medical Council, an eminently conservative supervisory body for the ­profession, would react badly to the Guide’s proposal, immediately accusing them of ‘unethical exercise’ of the profession. (Palombini and Del Barrio, 2021, 208)

 Available at: https://www.fcm.unicamp.br/fcm/sites/default/files/paganex/guia_gam_para_dowload_com_correcoes.pdf 12  There is also, in Brazil, the Moderator Support Guide (2014) which aims to help health professionals working in RAPS who want to start GAM groups in their workplaces. There is even a formal procedure for contracting the service. Available at: https://www.fcm.unicamp.br/fcm/sites/ default/files/paganex/guia_gam_moderador_-_versao_para_download_julho_2014.pdf 13  User report published on the site MadinBrasil might challenge this assertion. https://madinbrasil. org/2020/10/vozes-desmedicalizantes-amor-odio-e-respeito-pelos-psicofarmacos/ 11

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We see then that there were underlying political and epistemological motivations for the exclusion of the second part of the Canadian guide.14 Another particularity of the Brazilian GAM is the emphasis on grouping, considering the general context in Psychosocial Care Centres (CAPS) and the dynamics of their services. The written language was also adapted. The questions addressed to users  – unlike the Canadian guide that uses the pronoun ‘I’ (emphasis on self-­ reflection)  – are constructed using the pronouns ‘you’ and ‘we’, reinforcing the dialogic, collective and co-management aspect. In addition, there is concern about the use of easier language (avoiding highly technical terms), taking into account the Brazilian context of enormous social inequality and, therefore, serious inequity of access to material and cultural resources. The Brazilian personal GAM guide proposes a six-step process, which, like the Canadian guide, entails reflection and action: (1) Knowing a little about yourself; (2) Observing yourself; (3) Expanding your autonomy; (4) Talking about psychiatric medications; (5) Where are we going? (6) Planning our actions; Annex 1: Information on some psychiatric drugs; Annex 2: Information on some drug interactions; Annex 3: Information on some medicinal plants; Annex 4: Law 10,216: Psychiatric Reform Law. Throughout the reading, the user is led to reflect on the way psychiatric medication became part of his life, about his rights as a user of the mental health network, about his experience with the medication, about his network of support and about the possibilities of alternative treatments to which he may have access. The common thread, throughout the discussion on all these topics, is related to an appreciation of the user’s experience and the increase of personal control over the use of the medication, counting on the support of health professionals and the support network. (Santos 2014, p. 30)

An important initiative was the creation, in 2017, of the International Observatory of Gaining Autonomy & Medication Management (GAM) Practices,15 a collaborative university network for the production of knowledge, support and promotion, comprising several Brazilian public and private universities, in addition to Universitat Rovira i Virgili (Spain) and Université Montréal (Canada). It is currently under the coordination of UNIFESP (Campus Baixada Santista  – Prof. Luciana T. Surjus). The intention is to strengthen the exchange of knowledge and experiences between researchers in the different places where the strategy has been implemented. Since its establishment, GGAM-BR has been widely disseminated in several regions of the country. Experiences have been reported in academic works: dissertations, theses, papers, especially in the areas of psychology, medicine and collective health. It is also worth mentioning, as a Brazilian particularity, the use of GAM experiences with children and adolescents in CAPS-i (Caliman and Cesar 2020), as well as with users undergoing treatment due to abuse of or dependence on alcohol  It is known that in Brazil, the Federal Council of Medicine has supported a return to a hospitalbased model of care, representing a significant setback in the politics of mental health in Brazil and a threat of the return to oppressive practices and violations of human rights. 15  Available at: https://observatoriogam.unifesp.br 14

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and other drugs in CAPS-AD. According to Ferreira et al. (2021), the problem, in this case, lies in the recurrent cross-use of psychiatric drugs, illicit drugs and alcohol, which intensifies the health risks, evidencing the weaknesses of RAPS in the care of people who use different drugs. Furthermore, publications by researchers in GAM, based on their experiences, reveal that this strategy has had positive effects both for service users and for mental health workers. The latter found listening to users to be an educational experience, leading them to rethink their clinical performance from another perspective. (Santos et al. 2020). According to the authors, GGAM-BR has proved to be an important tool in promoting autonomy and in building more dialogical relationships between individuals involved in mental health treatments, challenging the traditional hierarchy between legitimized and subjected knowledge. The devices used in GAM, such as institutional support, matrix support, groups and conversation circles as well as its participatory and co-management way of operating focus on the micropolitics of relationships, strengthening the meaning of terms such as democracy, citizenship and autonomy. This is crucial for effective psychosocial care and for the validity of the Unified Health System in accordance with its principles. In addition, after ten years of GAM in Brazil, we have noticed its proliferation through the psychosocial care network, reaching primary care services, those aimed at users of alcohol and other drugs and also those dedicated to childhood and youth. This expansion of the strategy has given rise to an inventive and localized use of the GAM-BR guide, showing that, if its principles are preserved, the possibilities for working with the GAM strategy are manifold. (Ferrer et  al. 2020, p. 5)

2.5 Conclusion It is noteworthy that GAM has its origins in the movement of survivors of psychiatry, comprising current and former psychiatric patients who felt, to some extent, harmed by the treatments they received. In Brazil, on the other hand, it was an initiative of researchers and mental health workers who, through intervention groups, considered the experience and desires of potential users in the development and adaptation of the strategy. There is an important question to be asked here. In Brazil, there is a variety of organized movements of users of mental health services. However, why is there not, as in the United States, England and Canada, a movement of ex-users/survivors of psychiatry? According to Freitas (2021): In the latter case, the explicit message to society would be that despite having been victims of psychiatry, despite personal and intersubjective damage, they managed to ‘survive’ psychiatry. How many important things would these movements be teaching Brazilian society? How much would health professionals be learning from these life experiences? Where there are organized movements of ‘ex-users’ and ‘survivors’ of psychiatry, cracks develop in the ‘mainstream discourse’ of psychiatry and seeds of the ‘new’ can germinate. (Freitas 2021, n/p)

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In answer to the question, Freitas (2021) argues that the Brazilian Psychiatric Reform has emphasized the displacement of care provided in institutions to community-­based care, without, however, offering alternative tools to those of diagnosis and drug treatments. And in the community-based services, the change was towards an expansion of the market for the exercise of psychiatric power itself, despite recognition that there is no lack of good intentions on the part of professionals. So, if these initiatives arise from within the State, and are professional-­ dependent, they are subject to political forces, such as those that precluded interpretation the second part of the Canadian guide. Finally, it is worth presenting some quantitative data that corroborate the assertion by Freitas (2021). In a survey (Silva et al. 2020) with users (n = 467) of 11 (eleven) CAPS of different modalities – CAPS I, II, III/ CAPS-i and CAPS-AD – aiming to understand the prescription of psychotropic drugs within the services of a region of MG, the common practice of polypharmacy is highlighted: The results obtained in this region corroborate other studies that indicate an average use of 2 to 3 medications per patient for the treatment of mental disorders. However, highlighting the greater number of drugs prescribed in CAPS-AD and CAPS III, with above-average values ​​may identify the need to prioritize these types of service with regard to monitoring the use of drugs. (Silva et al. 2020, p. 2877)

As highlighted, one of the most important manifestations of psychiatric iatrogenics refers to the practice of polypharmacy and drug interactions that can even lead to hospitalization and death of users of the mental health services. Considering the fine line between care, control and harm in psychiatric clinical practice, it is important to reflect on the extent to which GAM experiences in Brazil have been effectively able to confront the medicalizing logic in the assistance offered within the substitute mental health services.

References Amarante, Paulo, and Fernando Freitas. 2015. Medicalização em Psiquiatria. Coleção Temas em Saúde. Rio de Janeiro: Editora Fiocruz. Caliman, Luciana Vieira, and Janaina Mariano Cesar. 2020. A GAM no ES: invenções com crianças, familiares e trabalhadores. Rev. Polis Psique. https://doi.org/10.22456/2238-­152X.104628. Caponi, Sandra. 2019. Uma sala tranquila: neurolépticos para uma biopolítica da indiferença. São Paulo: LiberArs. Conrad, Peter. 2007. The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore: The Johns Hopkins University Press. Fava, G.A., and C.  Rafanelli. 2019. Iatrogenic factors in psychopathology. Psychotherapy and Psychosomatics 88 (3): 129–140. Ferreira, Indianara Maria Fernandes et al. 2021. Gestão Autônoma da Medicação em CAPS-AD: fronteiras e borragens entre drogas prescritas e proscritas. Cadernos Brasileiros de Saúde Mental/Brazilian Journal of Mental Health. https://periodicos.ufsc.br/index.php/cbsm/article/ view/76792. Accessed 2 Apr 2022. Ferrer, Ana Luiza, Analice de Lima Palombini, and Marcos Adegas de Azambuja. 2020. Gestão Autônoma da Medicação: um olhar sobre dez anos de produção participativa em saúde mental a partir do Brasil. Revista Polis e Psique. 10: 1–8.

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Foucault, Michel. 1976. Histoire de la folie a l’age classique. Première Preface. Paris: Gallimard. ———. 2004. A ética do cuidado de si como prática da liberdade. In Michel Foucault. In Ética, sexualidade, política. Ditos & Escritos V, 264–287. São Paulo: Forense Universitária. ———. 2006. O poder psiquiátrico: curso no Collège de France (1973–1974). São Paulo: Martins Fontes. Freitas, Fernando. 2021. Reforma Psiquiátrica e o Movimento Organizado de Usuários. Por que não há Movimentos de Ex-Usuários ou de Sobreviventes da Psiquiatria no Brasil? In Blog MadInBrasil. https://madinbrasil.org/2021/05/reforma-­psiquiatrica-­e-­o-­movimento-­ organizado-­de-­usuarios-­por-­que-­nao-­ha-­movimentos-­de-­ex-­usuarios-­ou-­de-­sobreviventes-­da-­ psiquiatria/. Accessed 5 Apr 2022. Gaudenzi, Paula, and Francisco Ortega. 2012. O estatuto da medicalização e as interpretações de Ivan Illich e Michel Foucault como ferramentas conceituais para o estudo da desmedicalização. Interface – Comunicação, Saúde, Educação 16 (40): 21–34. Guy, Anne, et al. 2020. The ‘patient voice’: Patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125320967183. Illich, Ivan. 1975. A expropriação da saúde: nêmesis da Medicina. Rio de Janeiro: Nova Fronteira. Moncrieff, Joana. 2008. The myth of the chemical cure: A critique of psychiatric drug treatment. London: Palgrave Macmillan. Onocko-Campos, Rosana et al. 2012a. Guia da Gestão Autônoma da Medicação – GAM. DSC/ FCM/UNICAMP; AFLORE; DP/UFF; DPP/UFRGS. https://www.fcm.unicamp.br/fcm/sites/ default/files/paganex/guia_gam_para_dowload_com_correcoes.pdf. Accessed 15 Jan 2022 ———. 2012b. Adaptação multicêntrica do guia para a gestão autônoma da medicação. Interface – Comunicação, Saúde, Educação. https://doi.org/10.1590/S1414-­32832012005000040. Palombini, Analice, and Lourdes Rodriguez del Barrio. 2021. Gestão Autônoma da Medicação, do Quebec ao Brasil: uma aposta participativa. Saúde em Debate 45: 203–215. Regroupement des ressources alternatives en santé mentale du Québec; Association des groupes d’intervention en défense des droits en santé mentale du Québec; ERASME. 2019. GAM  – Gaining Autonomy & Medication. My personal guide. Québec: Regroupement des ressources alternatives en santé mentale du Québec. http://www.rrasmq.com/GAM/documents/ GuideGAM-­EN-­2019.pdf. Accessed 4 Apr 2022. Rose, Nikolas. 2019. Our psychiatric future: The politics of mental health. Cambridge: Polity. Santos, D. V. D. D. 2014. A gestão autônoma da medicação: da prescrição à escuta. PhD thesis. Universidade Estadual de Campinas. Santos, D.V.D.D., C.  Federhen, T.A.D.  Silva, I.R.D.  Santos, C.D.A.  Levino, R.T.  Onocko-­ Campos, and S. Stefanello. 2020. A Gestão Autônoma da Medicação em Centros de Atenção Psicossocial de Curitiba (PR). Saúde em Debate. https://doi.org/10.1590/0103-­11042020E315. Silva, Sarah Nascimento, Marina Guimarães Lima, and Cristina Mariano Ruas. 2020. Uso de medicamentos nos Centros de Atenção Psicossocial: análise das prescrições e perfil dos usuários em diferentes modalidades do serviço. Ciência & Saúde Coletiva. https://doi. org/10.1590/1413-­81232020257.23102018. Surjus, Luciana Togni de Lima e Silva. 2019. Observatório Internacional das práticas de Gestão Autônoma da Medicação (GAM). VII Congresso Internacional da ABRAMD. https://www. abramd.org/download/download?ID_DOWNLOAD=82. Accessed 15 Feb 2022.

Chapter 3

Practice, Human Flourishing and Centres for Psychosocial Attention: A MacIntyrean Analysis from Both the User’s and the Community’s Standpoints Anna Caramuru Pessoa Aubert

and Arthur Cezar Alves de Melo

Abstract  Centres for Psychosocial Attention (CPAs) were created with the purpose of treating people with mental disorders, while integrating them into their communities, fitting, therefore, into the outpatient model, instead of the asylum one. Because of the communitarian aspect of CPAs, we believe that philosopher Alasdair MacIntyre could provide us with interesting tools to consider the ethical role played, even if just in theory, by these Centres, not only through the standpoint of its users and their insertions into their families and community life, but also considering the advantages for other community members that could come of this integration. In light of this, the purpose of this paper is to verify, employing MacIntyre’s notions of ‘practice’ and ‘human flourishing’, a) if CPAs can contribute in any way to ethical development (i.e., development of virtues); b) how CPAs’ users can benefit from their insertion into communities; and c) how to evaluate the advantages for the flourishing of other community members in integrating people coming from these Centres. In the end, we will argue that this institution is of paramount importance for the community’s and its members’ flourishing. Keywords  Centres for psychosocial attention · Community life · Ethical role · Human flourishing · Integration · Outpatient model · Practices

A. C. P. Aubert · A. C. A. de Melo (*) Federal University of Rio de Janeiro, Rio de Janeiro, Brazil e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_3

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3.1 Introduction With the Psychiatric Reform, Brazil left behind, at least in theory, the preference for the interment in mental asylums, in exchange for the outpatient model, allowing for Centres for Psychosocial Attention (CPAs1) to be created with the purpose of treating people who were suffering psychologically, while integrating them into their communities (Barbosa-Fohrmann and Martins 2021, p. 9). With this in mind, we believe that Alasdair MacIntyre may provide us with some very interesting tools to reflect on the role played, even if just in theory, by these Centres. And although it is more common to look at CPAs as instruments of reinsertion of its users into their families and into community life, we will also inquire about the advantages for other community members that can come of this integration. Hence, the purpose of this paper is to verify, employing a MacIntyrean approach, (a) if CPAs can contribute in any way to ethical development (i.e., to the development of virtues); (b) how CPAs’ users can benefit from their insertion into their communities; and, finally, (c) how we could evaluate the advantages for the flourishing of other community members in integrating people coming from these Centres. In order to achieve our goals, we will be utilising MacIntyre’s notions of ‘practice’ and ‘human flourishing’ as theoretical tools to analyse the proposals and goals established by CPAs. We will start by briefly discussing the creation of CPAs in the context of the Psychiatric Reform in Brazil, outlining how these Centres deal with users, family members and the community. Next, we will lay down the concepts of ‘practice’ and ‘human flourishing’ as developed by MacIntyre and, then, we will apply MacIntyre’s ethical approach to CPAs, discussing, first, how flourishing happens inside these Centres and, after, (i) how the flourishing of communities encompasses the generation of benefits for its most vulnerable members, serving as an indicator for measuring the community’s degree of flourishment; (ii) how maintaining contact with people who have trouble developing their own practical reasoning in higher degrees – such as those with psychosocial disabilities or mental disorders – may bring us closer to a condition that all of us might experience someday, expanding our self-knowledge and understanding of how it would be to live with different degrees of dependence and vulnerability; and (iii) how the degree of dependency of a person with a severe psychosocial disability or mental disorder exemplifies a demand that we should be willing to respond to in order to truly exercise the virtue of ‘just generosity’, as outlined by MacIntyre.

 It should be noted that in Portuguese the mentioned ‘Centres for Psychosocial Attention’ or ‘CPAs’ are called ‘Centros de Atenção Psicossocial’, and abbreviated as ‘CAPS’. 1

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3.2 Centres for Psychosocial Attention 3.2.1 Psychiatric Reform In the last decades of the twentieth century, the Psychiatric Reform started to fall into place, and was later materialised by Law no. 10.216,2 which went through 12 years of law-making, suffering significant changes in its content that made it less innovative than it could have been (Martins 2020; Amarante 2007). Still, before the Psychiatric Reform, the asylum model prevailed as a form of care, and those considered to be mentally ill would, as a rule, be institutionalised and medicalised. With the reform, there was a shift to the outpatient model, which consisted of the care for people outside of psychiatric facilities, integrated in their families and communities. Public policies were no longer officially based on segregation and hospitalisation, but on social and family reinsertion (Amarante 2007). As put by André Ricardo Nader, within this new model of care, “not excluding, more than the final goal, is a condition of the process” (Nader 2017, p. 20; our translation). Among the different public institutions which carry the spirit of that Reform, the Centres for Psychosocial Attention are notable ones, and occupy the main place in this paper. As part of a social movement, the Centres for Psychosocial Attention were implemented by Health Ministry’s ordinance no. 224/92,3 and were regulated by the ordinance no. 336/02.4 These institutions perform, in terms of strategy to promote articulation, functions as the following ones: they organise the community care network, guide mental health policies, develop therapeutic projects within the community, provide medicines, among other occupations (Ministério da Saúde et  al. 2004). Besides, Schrank and Olschowsky (2008) state that these Centres focus on the deinstitutionalization of patients, distancing themselves from more traditional psychiatric institutions (marked by segregation based on diagnosis and prognoses of mental illnesses), while employing more inclusive devices that allow for other ways of seeing and dealing with different subjectivities on more complex levels.

3.2.2 General Functioning Schrank and Olschowsky (2008), through a Foucauldian interpretation, maintain that CPAs’ teams are composed of professionals from different fields, with an interdisciplinary outline that aims to decentralise both knowledge and power. Analysing CPA ‘II Fragata’, located in the state of Rio Grande do Sul, for instance, the researchers verified the presence of a variety of professionals working there: two  Cf. Brazil (2001).  Cf. Ministério da Saúde (1992). 4  Cf. Ministério da Saúde (2002). 2 3

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psychiatrists, two nurses, two nursing technicians, a nursing assistant, a social worker, three psychologists, two physical educators, an artist, an artisan, three officers, three cooks, three municipal guards and a person to assist with general services (Schrank and Olschowsky 2008). This structure, we believe, makes the Centre for Psychosocial Attention an institution singularly capable of humanising  – both in theory and in practice – the treatment of people with psychosocial disabilities and mental disorders. From 1998 to 2015, the number of CPAs in Brazil went from 148 to 2462 (Ministério da Saúde and Coordenação de Saúde Mental, Álcool e Drogas 2017 quoted in Conselho Federal de Psicologia et al. 2018, p. 31). This means that the outpatient model is, in fact, prevailing more each day, even if issues remain, such as the lack of facilities in some municipalities, and the fact that there are still people living inside psychiatric institutions in Brazil today, experiencing serious human rights violations.5

3.2.3 User, Family and Community The interesting thing about CPAs is that the activities offered by these Centres are not only meant for those individuals who are suffering psychologically, but also for their families and communities, with activities developed along with neighbourhood associations and other institutions in the community that consist, for example, of parties, walks, events and so forth (Schrank and Olschowsky 2008). In that sense, the goal seems to be utilising the community as an instrument for the integration of users, an aspect that is illustrated by the fact that the Health Ministry’s ordinance that regulates the Centres for Psychosocial Attention mentions in five different articles that patients should be integrated into their communities. One form of integration facilitated by these Centres is family insertion, which entails family group activities, individual care, reaching out to family members, workshops and home visitations. Family group activities are the most common ones, and enable interactions among the participants, who exchange their knowledge and history. In view of this, members of the group, guided by CPAs’ professionals, get to share their experiences, accessing different perspectives on the same problem, while learning how to tend to the needs of family members who are  It is also worth mentioning that according to a recent national report on Therapeutic Communities – instruments that fit more into the mental asylum model than into the outpatient one –, when patients institutionalised in these spaces have contact with CPAs, it is only for them to see psychiatrists who prescribe them drugs (often excessively), instead of actually getting in touch with the activities of the CPAs that facilitate familiar and community integration. So, for Therapeutic Communities, CPAs are used, many times, as mere instruments of medicalization (Conselho Federal de Psicologia et al. 2018). 5

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suffering psychologically. In this scenario, the group coordinator is responsible for paying close attention to the singularities of each user, providing personalised care throughout the therapeutic process, while encouraging family members to be part of the treatment process, overcoming any resistance that might have been present initially (Schrank and Olschowsky 2008). On a daily basis, family members accompany users at the Centre, and there are also activities such as assemblies, parties and group encounters that enable the construction of bonds and communication between user and family, allowing them to share their struggles with one another (Schrank and Olschowsky 2008). Workshops, for instance, provide users with means for their reintegration, overcoming their isolation and allowing the work carried out in these spaces to be extended to the family environment, promoting new ways of dealing with daily challenges (Rauter 2000 quoted in Schrank and Olschowsky 2008, p.  131). According to Schrank and Olschowsky (2008), the workshops also allow CPAs’ users to gain autonomy and to be recognized as citizens. This requires assistance from the family, “as the user needs to feel supported to produce connections between the various aspects of daily life” (Schrank and Olschowsky 2008, p.  131; our translation). Another facet of family integration is illustrated by home visitation, which allows the Centre’s staff to get to know the family dynamics and the home environment, in addition to providing another opportunity for the interaction with the family, improving the care given at home (Schrank and Olschowsky 2008). An important tool utilised by CPAs’ professionals to assimilate families in the treatment of users is reaching out to familiars through the aforementioned home visitations, but also through phone calls to the family. The suggested course of action for the staff is to “pick up the phone and call people who do not usually go to CPAs” (Schrank and Olschowsky 2008, p. 132; our translation). The idea is to bring the distant familiar closer to the user and to the Centre, adjusting to everyone’s schedules (Schrank and Olschowsky 2008). Finally, there are also activities such as commemorative parties (e.g., Christmas and Easter), as well as events held to promote “family-user-community-technician integration” (Schrank and Olschowsky 2008, p. 133; our translation). Overall, CPAs’ initiatives seem to be very positive for the development of users, since they emphasise their integration with their families, and insertion in public and urban spaces, focusing on how this integration could help them flourish as subjects. This is, indeed, an important aspect of this form of care that we wish to explore further. However, there is yet another question we aim to address in this paper, which is: what advantages might there be for the flourishing of other community members in integrating people coming from these Centres, considering, here, the ethical approach of Alasdair MacIntyre?

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3.3 Practice and Human Flourishing 3.3.1 Choosing Concepts As explained above, we will investigate, adopting Alasdair MacIntyre’s approach, in what ways CPAs can help users and communities to develop ethically. In order to achieve that, we will resort to two notable concepts employed by MacIntyre: practice and human flourishing. The first was described in After Virtue (2007), in which the author presented his version of classical ethics. The latter was detailed in Dependent Rational Animals (1999), in which MacIntyre inserted human vulnerability and biology into his ethical thinking.6 These two concepts were chosen because of the specific role that they play in the configuration of Ethics as developed by MacIntyre, and on account of their usefulness to analyse some of CPAs’ activities, as we intend to make clear throughout this paper.

3.3.2 Practice Firstly, it is important to mention that the concept of practice, according to MacIntyre (2007), does not coincide completely with the meaning usually ascribed to the word. The author states: By a ‘practice’ I am going to mean any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended. (MacIntyre 2007, p. 187)

It is a concept, we believe, endowed with many nuances. For the purposes of this chapter, it is enough to reflect on four elements that underlie it: the distinction between internal goods and goods external to the practices; practice as a means for developing virtues; the fundamentally cooperative character of this sort activity; and the difference between practices and institutions. The realisation of goods internal to practices, according to MacIntyre, can only occur through engaging in a given practice. Goods external to practices, on the other hand, are linked to contingencies of the environment in which the practices take place, and the activities themselves are not essential for the attainment of such goods (MacIntyre 2007, p. 188). Employing the Korean martial art of ‘Taekwondo’ as an example and based on the explanations given by MacIntyre (2007) about the  These prominent features of After Virtue (MacIntyre 2007) and Dependent Rational Animals (MacIntyre 1999) were described by Arthur Cezar Alves de Melo, co-author of this paper, similarly and in more detail in other opportunities. Cf. Melo (2021a, b). 6

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types of goods, it is possible to consider both the development of a specific fighting technique and the self-knowledge acquired by the body through practising a form of martial arts as internal goods to the practice in question, while any pecuniary prizes or fame achieved in Taekwondo championships would be, in light of the MacIntyrean notion of ‘practice’, goods external to the activity. Such considerations, we believe, help to clarify the definition of internal goods in relation to practices, and to elucidate the aforementioned MacIntyrean statement that the search for standards of excellence in these activities favours the achievement of internal goods. Furthermore, the search for goods internal to practices demands, according to MacIntyre (2007), the presence of virtue, defined, in the context of practices, as “(...) an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods” (MacIntyre 2007, p. 191; author’s italics). The author, in After Virtue (2007), develops his conception of virtue through three stages: the already mentioned practices, the human life conceived as an unity and with narrative form, and traditions. For the time being, however, working with the first stage will suffice. From this perspective, it is already possible to conclude that the virtues developed through the exercise of practices are precisely what allow practitioners to achieve the goods internal to those practices. The search for such goods, according to MacIntyre (2007, p. 191), implies relating to other people engaged with that same practice and requires that one acquires the ability to face possible risks that may self-endanger him or her, the ability to evaluate what is due to each person, and the ability to listen to remarks about their own inadequacies and to respond to those remarks in accordance with reality. Hence, the author considers that the virtues7 which manifest such abilities are essential to any practice as it was characterised. Considering these observations, it is possible to verify the fundamentally cooperative character of the development of virtues in the MacIntyrean approach. Furthermore, participation in practices also require, according to MacIntyre (2007, p. 194), contact with a tradition; in other words, the engaged agent establishes a relationship with practitioners from previous periods, “particularly those whose achievements extended the reach of the practice to its present point.” (MacIntyre 2007, p. 194). MacIntyre (2007, p. 194) establishes yet another distinction of interest for this paper: practices are not to be confused with the institutions that promote them. To better illustrate this, let us consider, for instance, the fact that a football club should not be mistaken for the practice of football, as a school of psychoanalysis should not be mistaken for the practice of psychoanalytic therapy. Moreover, the author emphasises that institutions deal primarily with goods external to the practices, which he judges plausible if institutions intend to maintain the practices contained in them

 Considering the order of abilities here exposed, they are, according to MacIntyre (2007, p. 191), courage, justice, and honesty. 7

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and themselves. However, practices, with regard to institutions, rely on virtues: “[w]ithout them, without justice, courage and truthfulness, practices could not resist the corrupting power of institutions” (MacIntyre 2007, p. 194). In light of this, we intend to discuss, in the following section of this paper, how CPAs, as institutions, are capable of promoting practices, highlighting the dynamics between internal and external goods. Before we do that, having elucidated the concept of practice and contextualised its importance considering the scope of this research, we will move on to the exposition of another MacIntyrean concept.

3.3.3 Human Flourishing In After Virtue (2007), the ethical conception of good appears in specific contexts, such as when MacIntyre deals with practices, which possess internal goods; when he deals with life, perceived as a unified narrative, which can be described as good under given circumstances; when the author discusses traditions, that may or may not be good under specific conditions. In Dependent Rational Animals (1999), the philosopher remains concerned with the concept of good, but within broader terms, emphasising what is good for humans as such: (…) for each individual there is the question of whether it is good for her or him that the goods of this or that particular practice should have this or that place in her or his life. And for every society there is the question of whether it is good for that society that the goods of this or that particular practice should have this or that place in its common life. So we need to make a third type of judgement. (…) We therefore need to distinguish between what it is that makes certain goods goods and goods to be valued for their own sake from what it is that makes it good for this particular individual or this particular society in this particular situation to make them objects of her or his or their effective practical regard. And our judgements about how it is best for an individual or a community to order the goods in their lives exemplify this third type of ascription, one whereby we judge unconditionally about what it is best for individuals or groups to be or do or have not only qua agents engaged in his or that form of activity in this or that role ou roles, but also qua human beings. It is these judgements that are judgements about human flourishing. (MacIntyre 1999, p. 66, 67; author’s italics)

MacIntyre binds the idea of flourishing to the development of the potentialities peculiar to each species (MacIntyre 1999, p. 64). It is clear for us, in light of this and of the quotation above, that the assessment of human flourishing involves an assessment of practices, as described in the previous subsection. However, it also encompasses an evaluation regarding the way we live as beings that are constituted by a specific form: human animals, considered individually, but also as members of communities. In this context, MacIntyre (1999, p. 67) maintains that it is a typical human characteristic to inquire and discuss why one should follow a certain line of action and not another, as well as to evaluate manifestations of practical reasoning that underlie human actions connected to such discussions. Then, according to MacIntyre, for

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humans to flourish as members of their species they are required to perceive themselves as practical reasoners that will employ goods, good deeds and a good way of living as their objects of reflection. It is not surprising, therefore, that MacIntyre believes that human flourishing, regardless of any specific context, presupposes the formation of human beings as independent practical reasoners. Human conditions for flourishment advance when they apply the abilities that characterise them in that way.8 This process of development also presupposes the engagement of the individual in collaborative networks, in which someone receives what they need and, at some point, may be able to give others what they are lacking (MacIntyre 1999, p. 76–77, 99). In this regard, we consider the contribution of others – especially those who are part of the same community – to the formation of one’s practical reasoning a key aspect of the MacIntyrean reflection on human flourishing. The links between the individual’s development as a practical reasoner and their community engagement are further explored by the author in the following terms: Practical reasoning is by its nature, on the generally Aristotelian view that I have been taking, reasoning together with others, generally within some determinate set of social relationships. Those relationships are initially formed and then developed as the relationships through which each of us first achieves and is then supported in the status of an independent practical reasoner. They are generally and characteristically first of all relationships of the family and household, then of schools and apprenticeships, and then of the range of practices in which adults of that particular society and culture engage. The making and sustaining of those relationships is inseparable from the development of those dispositions and activities through which each is directed towards becoming an independent practical reasoner. So the good of each cannot be pursued without also pursuing the good of all those who participate in those relationships. For we cannot have a practically adequate understanding of our own good, of our own flourishing, apart from and independently of the flourishing of that whole set of social relationships in which we have found our place. (MacIntyre 1999, p. 107–108)

Therefore, it is precisely inside community life that individuals may develop themselves as independent practical reasoners, and not outside of it. Furthermore, in addition to the development of practical reasoning, the relationships required in order to foster human flourishing, according to MacIntyre (1999, p. 108), presuppose the provision of care, which people must receive when they experience different adversities throughout life, or when they are infants or elders. The flourishing of communities marked by relationships of this nature occurs, according to MacIntyre, when practical rationality guides the search of the members for the common good. Such a flourishing state, the author affirms, necessarily encompasses the generation of benefits for those who are limited in their ability to develop their own practical reasoning or face some form of disablement. This means that the degree of a community’s flourishment can be measured by such persons’ flourishing (MacIntyre 1999, p. 108–109).  Some of the virtues that are connected by MacIntyre (1999, p. 92) to the formation of the independent practical reasoner, encompassing response to various situations and practical reasoning, are courage, patience, justice, temperateness, and cheerful wit. 8

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Considering the MacIntyrean approach, we do not see any contradiction between the individual good and the common good. In fact, the philosopher (MacIntyre 1999, p. 109) contends that the search for the individual good – and even its characterization – hinges on the assimilation of the goods which are common as their own good by the members of the community; the author maintains, moreover, that the common good is not to be mistaken for the accumulation of individual goods and that individual good surpasses the common good. By dealing with the development of practical reasoning in these terms, MacIntyre, as we understand it, provides a theoretical framework that allows us to understand the process of human flourishing as an eminently community enterprise, notwithstanding the fact that the resulting individuals differ one from the other, in reason of their own specificities. On the other hand, since the common good, which is in every member of the community’s best interest, doesn’t comprise the individual good in its entirety, there is room for people to flourish in their own particular ways, enriching the community in unique and irreplaceable manners. Moreover, MacIntyre (1999) describes virtues he considers to be essential for the development of independent practical reasoners emphasising dependence as an essential aspect of being human. Presenting these virtues, classified as virtues of acknowledged dependence, the author works with two pillars: giving and receiving. In the first one, the virtue of ‘just generosity’9 is highlighted, a virtue which shapes human relationships in different ways. When pervaded by this virtue, relationships mobilise affections, leading to practical consequences such as the accommodation of a foreigner visiting the community and to tending to those experiencing pressing human needs10 (MacIntyre 1999, p. 126), like those related “to food, drink, clothing and shelter” (MacIntyre 1999, p. 127). After these needs are met, “what those in need then most need is to be admitted or readmitted to some recognized position within some network of communal relationships in which they are acknowledged as a participating member of a deliberative community” (MacIntyre 1999, p. 127). It is also important to mention that the attention given to people to whom the virtue of ‘just generosity’ is addressed does not hinge on the recipient of that action giving anything in return (MacIntyre 1999, p. 122, 126). In the second pillar, we find the virtues that MacIntyre (1999, p. 126–127) associates with the act of receiving, virtues that are essential in order for individuals to recognize themselves as dependents, escaping the illusion of self-sufficiency. These virtues of receiving, as he puts it, are needed “in order to sustain just those types of communal relationship through which the exercise of these virtues first has to be

 MacIntyre establishes the distinction between virtues of giving and virtues of receiving (1999, p. 126). However, he does not place ‘just generosity’ as part of the first group. In this paper, we adopt Melo’s position (2021b, p. 74), framing just generosity as part of the virtues of giving. We adopted this position considering that the exercise of just generosity results more directly in an action focused on attending to the necessities of others. 10  According to MacIntyre, ‘just generosity’ reaches this scope via the operation of the virtue of misericordia (MacIntyre 1999, p. 126). 9

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learned” (MacIntyre 1999, p.  127). The author (1999, p.  126), then, exemplifies those qualities: “knowing how to exhibit gratitude without allowing that gratitude to be a burden, courtesy towards the graceless giver, and forbearance towards the inadequate giver.” According to MacIntyre, the community that comprehends relationships marked by such virtues requires the promotion of a specific type of care, since “those in dire need both within and outside a community generally include individuals whose extreme disablement is such that they can never be more than passive members of the community” (MacIntyre 1999, p. 128); it is a form of care that is not conditional, however, “upon the contingencies of injury, disease and other afflictions’‘ (MacIntyre 1999, 128), since, in the author’s own words, “‘I might have been that individual’” (MacIntyre 1999, 128), that is, anyone might experience conditions of increased degrees of dependence and vulnerability over the years, including ourselves. For the author, then, we are all dependent and vulnerable, what sets us apart is in what degree our vulnerability and dependence manifest themselves, something that shifts throughout our lives. This condition of everlasting passivity, which MacIntyre attributes to having a severe disability (1999, p. 127), and the condition of being limited to develop independent practical reasoning (1999, p.  108) are especially relevant for this paper, since some users of CPAs may manifest them in various degrees. In the next section, we will explore the ethical repercussions of the way this institution works, focusing, first, on the flourishing of the users of the services provided and, secondly, on the flourishing of communities where these institutions are located.

3.4 Applying MacIntyre’s Ethical Approach to CPAs 3.4.1 Flourishing Inside the CPAs The mental asylum model differs from the outpatient one in many ways. One important aspect is that the mental asylum, as an institution, has a pedagogical effect of affirming a certain way of dealing with madness (Nicácio 1989), and so “it encompasses certain ways of understanding individuals considered to be mad, talking about them and acting upon them – effects of truth” (Nader 2017, p. 54; our translation). On the other end, the anti-asylum movement also “engenders its ways of understanding madness, since it defines the ways of confronting the mental asylum” (Nader 2017, p. 54; our translation). CPAs, as aforementioned, are part of the latter, and one of these Centres’ most important characteristics is the importance they pay to the community. The first way to go about the communitarian aspect of these Centres is, we believe, to think of them in terms of how collectiveness allows the users to flourish, considering, here, the concept of flourishing for MacIntyre, as outlined above.

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The condition of those who suffer psychologically can manifest itself in multiple ways and degrees, hence any attempt to stimulate the user’s flourishment must be pursued in accordance to their singularities,11 an important aspect when advocating for the flourishing of virtues. These singularities refer not only to subjects’ mental health, but also to the way they engage in society, as sons, daughters, friends, parents, partners, and so forth, which means they will have to learn how to deal with their passions, desires, etc., considering the singular conditions of their own existences. In other words, even though we are thinking about the subject as a member of a community, this community should not be perceived as one that seeks to impose a universal good that should be pursued by everyone the same way, but one that accommodates differences and distinctions between the individuals that live in it (Agamben 2013). Diversity is, in itself, an attribute repelled by Foucauldian disciplinary power (Foucault 1987, 2019) that underlies the treatment given to patients inside mental asylums, since the way people are diagnosed and medicated in these spaces reduces the complexity of human experiences and suppresses the different types of being and suffering (Nader 2017). Another important aspect of CPAs is that they, as an institution and at least in theory, combine the attention to the unique conditions of their users12 with the attention to community life, something made possible by these Centre’s values, practices and dynamics in the treatment of their patients and in the interaction of these users with the outside world. Prolific mechanisms in this sense are therapeutic workshops, which, according to a document from the Ministry of Health (Ministério da Saúde et  al. 2004), involve group activities developed under the supervision of

 During the roundtable ‘Deficiências, Inclusão e Fenomenologia’, when asked by Professor Ana Paula Barbosa-Fohrmann if MacIntyre’s work provided resources to think about human flourishing concerning people with severe cognitive or intellectual disabilities, Melo (2021a) answered that, from a Macintyrean approach, the people with severe cognitive disabilities’ flourishment would occur as long as they can accomplish practical reasoning, considering that people with this sort of disabilities have singular limitations. Melo maintained, however, that it does not prevent the participation of these people in their communities’ flourishment; they will have their necessities met and will flourish according to their capacities (2021a). We think that those considerations about flourishment are applicable to this paper, i.e., to the conditions of CPAs’ users with mental disorders and/or psychosocial disabilities. They, as we see it, will flourish and develop virtues, either in practices or by accomplishing independent practical reasoning in a broader sense, according to their own peculiar capacities and will enjoy the flourishing of their communities. 12  In this sense, “The practices carried out in CPAs characteristically occur in places which are open, welcoming and inserted inside the city, the district. These services’ projects many times surpass the physical facilities, seeking a social support net that might strengthen their actions, concerning themselves with the subject’s singularity, their history, their culture, and their daily life” (Ministério da Saúde et al. 2004, p. 14; our translation).” 11

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technical representatives of the institution, and cover modalities of expressiveness,13 income generation14 (IG) and the promotion of literacy.15 Considering what we have previously tried to demonstrate in Section 3.3.2, numerous activities that fit into the workshops of expressiveness and IG can be conceived as what MacIntyre describes as practices. This implies that, to some degree, CPAs’ users will come into contact with the socially constructed heritage of practices, which have their internal assets, their standards of excellence, all of which are assimilated and rooted in a broader16 context. It follows that, according to the peculiarities of each clinical condition, the workshops provide users with access to the experience of social engagement that will be demanded of them in the midst of community life. These workshops, which allow patients to engage in social practices, put them in contact with the internal goods that characterise group activities and, consequently, challenge and allow them to develop the qualities necessary to achieve internal goods. In this sense, the development of virtues, as happens inside a community, is afforded to these people, who can pursue them according to their own particularities and circumstances. There is, however, an underlying tension to the practices developed in this space: the protagonism of the therapeutic element, which operates, at first sight, as a good external to the activities, since such workshops are considered “one of the main forms of treatment” (Ministério da Saúde et al. 2004, p. 20; our translation). Hence, the following question arises: can the priority given to this therapeutic aspect lead to the corruption of practices by these Centres,17 hindering the development of virtues and, consequently, the implementation of the aforementioned activities? To answer this question, we propose to think about practices in a more general context, carried out by people who do not necessarily have a mental disorder or psychosocial disability. Based on the Macintyrean concept of practice, one can think of activities of many kinds. In all of them, it is assumed that their practitioners are receptive to subjecting themselves to certain parameters and procedures, dosing their internal tensions and adapting to the ‘universe’ of the practice in question. Now, it seems to us that the practices themselves contribute to this process of  Examples: “spaces for visual expression (painting, clay, drawing etc.), corporal expression (dance, gymnastics, and theatrical techniques), verbal expression (poetry, short stories, reading and writing texts, drama plays, and song lyrics), musical expression (musical activities), photography, and theatrical activities” (Ministério da Saúde et al. 2004, p. 20; our translation). 14  These workshops “function as instruments of income generation through learning a specific activity, which may be equal or different from the user’s profession. The workshops of income generation may be [of these kinds]: cooking, woodworking, sewing, photocopying, book selling, candle making, craftsman ships in general, ceramics, bijou, thrift store, etc.” (Ministério da Saúde et al. 2004, p. 20; our translation). 15  These workshops “allow users who have not had access to or could not remain at school to exercise writing and reading as an important resource for (re)building citizenship” (Ministério da Saúde et al. 2004, p. 21; our translation). 16  MacIntyre maintains that social traditions provide practices with a broader historical context in which they unfold (2007, p. 222–223). 17  This is a reference to the tension between practices and institutions mentioned in Section 3.3.2. 13

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forging a state of equilibrium when the practitioners train their abilities, pursuing a certain degree of concentration, a specific body rhythm, a way of observing human behaviour; or when they seek to act with justice, in order to evaluate their merits, and try to overcome their own limitations and personal challenges. Therefore, it is possible to maintain that this state of equilibrium, which makes the practitioner receptive to the ‘universe’ of that practice, is an indispensable condition in the search for the internal goods of these activities. Additionally, we believe that there is no reason not to consider that this state is itself an internal good that cannot, in fact, be absent in any practice, even if it varies depending on the particularities of each practice. Hence, the contradiction between the therapeutic element of the practices and the search for the internal goods that constitute it is only apparent. Evidently, the practices that are carried out inside the CPAs differ from practices carried out in other spaces and circumstances. There is a clear inflection: while in usual contexts equilibrium constitutes an internal good, in the eminently therapeutic context, the search for other internal goods – with the development of the virtues involved in it – is subject to the patient’s therapeutic process. Such a degree of subjection, however, cannot be defined a priori, considering that each clinical condition is unique. In conclusion, we believe that the emphasis given to the therapeutic component in the CPAs does not necessarily distort practices; in fact, such emphasis is, especially in the context of this institution, what allows the development of practices according to the demand of each patient, paving their way out so that they can perform them outside the Centre’s walls.

3.4.2 Flourishing, Vulnerabilities, and Dependency18 The goal of the outpatient model, as pointed out by Nader, is “to build a type of social organisation that is non-excluding, one that does not cease to change: a community to come” (Nader 2017, p. 21; our translation).

 In A posição estratégica da deficiência no projeto ético de Alasdair MacIntyre (2021a), Melo presented an ongoing research upon the strategic position that disability plays in MacIntyre’s ethics, specifically taking into account Dependent Rational Animals. In that opportunity, the co-author of this chapter concluded, among other things, that: (i) Within the MacIntyrean approach, disability plays a central role in ethical reflection, since it figures as a condition that everybody may experience someday; (ii) the potential for flourishment of persons with disability provides the standard for verifying if the state of flourishing is present or not in a communitarian level; (iii) the kind of regard necessary to nurture communities where the virtues tipically human and common good prevail is required by the  situation of  persistent passivity resulting from  a  severe disability, as the one experienced by a person with a severe cognitive disability; (iv) the communitarian flourishment, within this orientation, relies on including persons with disability and  providing them conditions for flourishing according to their potential (Melo 2021a). In Section 3.4.2 of this paper, we intend to explore these conclusions as points for orientation to be applied to CPAs. 18

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With that in mind, we wish to explore further, in this final subsection, three notions maintained by MacIntyre in Dependent Rational Animal, applied to CPAs. The first has to do with how the flourishing of communities encompasses the generation of benefits for the most vulnerable members, or who are limited in their ability to develop their own practical reasoning. As a result, the flourishing achieved by these members can serve as an indication of the degree of a community’s flourishment, i.e., if the most vulnerable members of a community were able to flourish according to their own individual potentialities, this means that the community that they belong to was also able to flourish. This is precisely the case here because, as seen above, the search for the individual good hinges on the search for the common good, which should be assimilated by the members of the community as their own good. CPAs, in this sense, collaborate in promoting communities’ flourishment, as long as they are successful in the goals they establish for the users, providing care attentive to the peculiar needs of patients and offering opportunities for the development of skills, virtues etc. A well-functioning community should be able to accommodate its members, regardless of their particularities, embracing diversity and using it to its advantage, caring for those with more significant degrees of vulnerabilities and dependency, while recognizing that we are all vulnerable and dependent19: Those are key aspects of being human, albeit with a variation in degrees over our lives, either because we are still infants, as a consequence of an accident or a disease, or due to pure and simple ageing. In this sense, CPAs, by mobilising efforts to satisfy the needs of people with some type of disability or mental disorder, materialise the type of care that, according to MacIntyre (1999, p. 127–128), characterises the communities pervaded by the virtues of giving and receiving, something that is not impaired because of afflictions, deficiencies, etc., of those dependent on care. Considering this last reflection, we move on to the second aspect we wish to explore, which relates to the fact that maintaining contact with people who have trouble developing their own practical reasoning in higher degrees may bring us closer to a condition that we might all experience someday,20 as illustrated above.

 The dependent and vulnerable condition of human beings was explained by MacIntyre (1999, p. 1) in the following terms: “We human beings are vulnerable to many kinds of affliction and most of us are at some time afflicted by serious ills. (…) It is most often to others that we owe our survival, let alone our flourishing, as we encounter bodily illness and injury, inadequate nutrition, mental defect and disturbance, and human aggression and neglect. This dependence on particular others for protection and sustenance is most obvious in early childhood and in old age. But between these first and last stages our lives are characteristically marked by longer or shorter periods of injury, illness, or other disablement and some among us are disabled for their entire lives.” 20  As we see it, this circumstance may generate impressions similar to MacIntyre’s reflection on disability: “(…) there is a scale of disability on which we all find ourselves. Disability is a matter of more or less, both in respect of degree of disability and in respect of the time periods in which we are disabled. And at different periods of our lives we find ourselves, often unpredictably, at very different points on that scale.” (MacIntyre 1999, p. 73). This notion, we conclude, enables people to get in touch with their own condition of dependence. 19

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This might help us expand our self-awareness about our vulnerable condition and even our understanding of how it may be to live with different degrees of dependence and vulnerability. CPAs, by prioritising the patient’s community insertion, give people who do not have a mental disorder the opportunity to get in touch with a way of being human that was possibly unknown to them, and to exercise virtues such as just generosity, tending to the user’s needs. Furthermore, these Centres can help to remove prejudices of members of the community through their contact with an unpredictable variety of conditions, degrees and limitations that can constitute a mental disorder or a psychosocial disability. Let us recollect, here, that when MacIntyre (1999) explores the virtues, he considers to be essential for the development of independent practical reasoning, he emphasises dependence as an essential aspect of being human, and highlights the virtue of recognizing such dependence. Furthermore, for members of the community, this might mean, we believe, the development of a deeper capacity for empathy, a preparation for what is to come, and an opportunity to further develop the notion21 from which MacIntyre (1999) derives the type of care necessary for the common good. Also, this experience of coexistence, and the self-awareness it implies, might assure that when we eventually grow older and more dependent and vulnerable, we will have the support of our fellow neighbours and of the community as a whole for dealing with the troubles we might face. In short, CPAs, by prioritising the patient’s integration, provide people who do not have mental disorders with a controlled confrontation with a way of being human that was possibly unknown to them and that potentially will be their own future condition. These Centres allow people to exercise virtues that will shape their flourishing and that of their community, and for them to nurture the form of care that, someday, they may need and that they certainly, to some degree, have already enjoyed in order to develop themselves as independent practical reasoners. Finally, the last aspect we wish to explore refers to the degree of dependency of a person that possesses a severe mental disorder or psychosocial disability, which serves as a good example of a demand that we should be willing to attend to in order to manifest the virtue of just generosity, as outlined by MacIntyre. This means that even if we disregard the previous aspects mentioned above, there is still value in acting in such a way that one manifests their own virtues. Following the consequences of ‘just generosity’, as it was presented in Section 3.3.3 of this paper, it is up to the members of a community to care for people with severe psychosocial disabilities or mental disorders, regardless of any contribution they might have given to them as individuals, or to the community as a whole. This is so because the virtue of just generosity, as MacIntyre (1999, p. 126) understands it, does not follow a proportional logic of giving something to a person after

21

 “‘I might have been that individual’” (MacIntyre 1999, p. 128).

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receiving something from them. It implies giving regardless of ever having received anything from the person to whom the virtue is addressed.22 We consider, therefore, that CPAs, with a therapeutic proposal that privileges the community integration of the users, materialise the virtue of just generosity by concentrating various means and efforts in and from the community in favour of meeting the specific demands that arise of mental conditions. Allied to the two other aspects already mentioned in this subsection, this element creates conditions for CPAs to foster the emergence of relationships conducive to the development of the virtues of acknowledged dependence and, consequently, the flourishing of the community and its members.

3.5 Conclusion In this paper, we have tried to verify whether and how Centres for Psychosocial Attention, in light of their design and purposes, can serve as a means to promote human flourishing, as it was employed by Alasdair MacIntyre. We have utilised, as reference, the standpoint of the users and of the members of the community where the institution is located. In Sections 3.2 and 3.3, we exposed, first, what these Centres are and elements of their functioning that are of interest to this research and, secondly, we highlighted important concepts of MacIntyrean ethics – practice and human flourishing – that allowed us, through their application, to interpret CPAs as potential promoters of virtues. In Section 3.4, we articulated the mentioned concepts and information with the functioning of CPAs, which led us to conclude, regarding CPAs’ users, that therapeutic workshops offer opportunities for patients to develop virtues by engaging in practices and preparing them to perform different activities outside the therapeutic environment. Furthermore, with regard to the community where the therapeutic institution is located, we found that: (i) the flourishing provided to CPAs’ users can indicate the degree of flourishing of communities for their own members; (ii) the integration of users into the community provides its members with knowledge of the condition of dependence and vulnerability that they might experience someday for various reasons, in addition to providing opportunities for the exercise of virtues like ‘just generosity’; (iii) CPAs materialise the virtue of ‘just generosity’ by concentrating efforts in favour of the care that is required when facing conditions of psychosocial disabilities and mental disorders.

 MacIntyre (1999, p. 126) sustains that “[j]ust generosity requires us to be uncalculating in this sense, that we can rely on no strict proportionality of giving and receiving. (…) those from whom I hope to and perhaps do receive are very often, even if not always, not the same people as those to whom I gave. And what I am called upon to give has no predetermined limits and may greatly exceed what I have received.” 22

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Since human flourishing is a community achievement, as the Macintyrean theoretical framework seems to indicate, we conclude that institutions such as CPAs are of paramount importance to achieve such flourishing, given that they (i) meet immediate human needs peculiar to a specific group that is characterised, potentially, by severe impediments; (ii) deal with care demands that could possibly be very demanding for isolated individuals, while allowing users to be integrated into their communities; (iii) create conditions for the generation of virtues, both for users and for the lato sensu community where they live in. In view of the above, we believe that, as a project to be implemented under a remarkable community orientation, CPAs have ample potential to give rise to the development of virtues and, consequently, to human flourishing, both in terms of users, individually, and of the communities that they inhabit. Undoubtedly, the reflections developed here suffer from the limitation of not resorting to abundant sociological studies able to describe in detail the implementation of the mechanisms that make up CPAs as a project. However, we believe that we were able to present some theoretical parameters that, on the one hand, allowed us to evaluate CPAs as ethical mechanisms for communities to thrive and, on the other, might offer a substrate for eventual empirical investigations that seek to reflect on the functioning of the institution having this social dimension, i.e., ethics, as a privileged universe of analysis.

References Agamben, Giorgio. 2013. A comunidade que vem. Belo Horizonte: Autêntica Editora. Amarante, Paulo. 2007. Saúde mental e atenção psicossocial. Rio de Janeiro: Fiocruz. Barbosa-Fohrmann, Ana Paula, and Laércio Melo Martins. 2021. Previsão constitucional do direito social à saúde mental: novos caminhos para a reforma psiquiátrica brasileira. Pensar 26 (1): 1–13. Brazil. 2001. Lei n° 10.216, de 6 de abril de 2001. Brasília: Presidência da República. http://www. planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm. Accessed 24 Apr 2022. Conselho Federal de Psicologia et  al. 2018. Relatório da Inspeção Nacional em Comunidades Terapêuticas. Brasília: CFP. https://site.cfp.org.br/publicacao/relatorio-­da-­inspecao-­nacional-­ em-­comunidades-­terapeuticas/. Accessed 24 Apr 2022. Foucault, Michel. 1987. Vigiar e punir: nascimento da prisão. Trans. Raquel Ramalhete. Petrópolis: Vozes. ———. 2019. História da Loucura. Trans. José Teixeira Coelho Neto. São Paulo: Perspectiva. MacIntyre, Alasdair. 1999. Dependent rational animals. Why human beings need the virtues. Chicago: Open Court. ———. 2007. After virtue. A study in moral theory. 3rd ed. Notre Dame: University of Notre Dame Press. Martins, Laércio Melo. 2020. Saúde Mental: paradigmas e reformas legislativas. Porto Alegre: Editora Fi.

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Melo, Arthur Cezar Alves de. 2021a. A posição estratégica da deficiência no projeto ético de Alasdair MacIntyre. Lecture presented at the round table ‘Deficiências, Inclusão e Fenomenologia’, On-line. Recording available on the NTDH UFRJ’s Youtube Channel. https:// www.youtube.com/watch?v=QkNWv1fSQhM&t=3513s.23 Accessed 22 Apr 2022. ———. 2021b. Bioaprimoramento moral: uma avaliação da proposta à luz da ética de Alasdair MacIntyre. Master Thesis, Universidade Federal do Rio de Janeiro. Ministério da Saúde. 1992. Portaria SAS/MS n° 224, de 29 de janeiro de 1992. Belo Horizonte: Secretaria de Estado de Saúde de Minas Gerais. https://www.saude.mg.gov.br/index. php?option=com_gmg&controller=document&id=836. Accessed 13 June 2022. ———. 2002. PORTARIA N° 336, DE 19 DE FEVEREIRO DE 2002. Brasília: Ministério da Saúde. https://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/prt0336_19_02_2002.html. Accessed 24 Apr 2022. Ministério da Saúde and Coordenação de Saúde Mental, Álcool e Outras Drogas. 2017. Panorama e Diagnóstico da Política Nacional de Saúde Mental. Quoted in Conselho Federal de Psicologia et al. 2018, 31. Ministério da Saúde et al. 2004. Saúde mental no SUS: os centros de atenção psicossocial. Brasília: Ministério da Saúde. http://www.ccs.saude.gov.br/saude_mental/pdf/sm_sus.pdf. Accessed 24 Apr 2022. Nader, André Ricardo. 2017. Entre a afirmação do manicômio e a afirmação de um modelo comunitário: fabricando formas de luta. Master Thesis, Universidade de São Paulo. https:// www.teses.usp.br/teses/disponiveis/47/47131/tde-­22052018-­174101/pt-­br.php. Accessed 24 Apr 2022. Nicacio, Maria Fernanda. 1989. Da instituição negada à instituição inventada. In Saúde e Loucura, 1 ed. Antonio Lancetti, 91–108. São Paulo: Hucitec. Rauter, Cristina. 2000. Oficinas para quê? Uma proposta ético-estético-política para oficinas terapêuticas. In Ensaios: subjetividade, saúde mental, sociedade, ed. Paulo Amarante, 267–277. Rio de Janeiro: FIOCRUZ. Quoted in Schrank and Olschowsky 2008, 131. Schrank, Guisela, and Agnes Olschowsky. 2008. O Centro de Atenção Psicossocial e as estratégias para inserção da família. Rev Esc Enferm USP. https://www.scielo.br/j/reeusp/a/skxLSVThZb 3bjP68Ms9NGJg/?lang=pt. Accessed 24 Apr 2022.

 This link refers to the roundtable ‘Deficiências, Inclusão e Fenomenologia’ in full, and not just the lecture A posição estratégica da deficiência no projeto ético de Alasdair MacIntyre (Melo 2021a). 23

Chapter 4

The Phenomenological Model as a Basis for the Inclusion of People with Intellectual Disabilities and Psychosocial Impact Laura Rueda Castro

Abstract  The inclusive proposals aimed at people with psychosocial disabilities lead us to review and synthesize the concepts and practices to establish foundations that support the actions taken towards their inclusion. This chapter reviews the approach of the phenomenological model as a substratum that validates as a right and as an ethical principle, the autonomy of people with disabilities, in the context of the transition from the classic notion that perceive disabilities as difficulties or limitations which people present, and that marginalize them from all social participation, to one in which ‘disability’ is conceived as a multidimensional phenomenon, resulting from the interaction of people with their environment. Thus, in the phenomenological view, persons with disabilities are seen as an expression of human existence; they are subjects committed to their social processes, involved with it and able to make valid decisions, which must be respected. In this chapter, we selected some ideas pertaining the model that support this inclusion process, discussed its ethical considerations, and then applied it to a case study. Keywords  Intellectual disabilities · Psychosocial disabilities · Phenomenological model · Autonomy · Inclusion

4.1 Introduction The phenomenological model derives from a solid training in the humanistic field, since, above all, it ought to value the human being taking as a starting point the multidimensionality of their existence, the relationship that they establish with their physical and social environment and from this point of view, be able to identify certain personal characteristics, and gauge the interference of them in their daily L. R. Castro (*) Faculty of Medicine, Department of Occupational Therapy, University of Chile, Santiago, RM, Chile e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_4

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performance. This will often affect their personal performance and, on many occasions, it will be the family who will feel affected by the characteristics of the person, without them even being aware of it. This approach seeks to identify these characteristics, and thus collaborate in the inclusion process, while assessing the importance of these characteristics. Its main purpose is to facilitate the understanding of people with disabilities through the establishment of a horizontal relationship with the affected people, assess their traits not for diagnostic purposes, but as a way of being and being in the world and, therefore, facilitating that they achieve their maximum performance, taking control over their own existence. In addition, to allow for freedoms to be taken in an epistemological position, in order to privilege the ethical, over the theoretical, in the therapist-patient relationship. ‘Freedoms’ refers to the use of two different methods of approaching reality: the categorical descriptive phenomenological and the dimensional descriptive phenomenological methodologies. The first facilitates the description of the elements and instruments of experiencing and the second facilitates the description of the dimensions of the self.

4.2 Background The phenomenological model derives from the existential examination of people and provides important explanations regarding human behaviour. The underlying motivation is a search for self-actualization. Life experiences and perceptions are intentional, or shaped by our own goals. Authenticity would arise from an opening to the experience to oneself and to others, from the active pursuit of goals. Viktor Frankl (1989), founder of logotherapy, proposes the existence of a ‘wanting to give meaning’ that leads to the discovery and choice of values, and to committing to a significant cause in life. The healthy balance would derive from a flexible and realistic self-image, which allows for the assimilation and perception of new experiences. The phenomenological theory has provided us with a great epistemological scheme for understanding the condition of having a disability, that ranges from the world of perception, thought, experience, messages, to the relationships between these aspects. In communicational terms, every statement, analysed within this model, is a valid reality, since regardless of whether it is empirically real, the message always carries a particular value. This conceptual scheme reconsiders the link between people who know how to do something and those who contribute themselves to the creation of each one’s unique project, which is structured in everyday life. Later, the individual particularities are blurred to then configure the general lines that support a restart to a new practical application. In a given social organization, with its own history, human behaviours are pre-established in a moment that precedes the integration of a particular way introduced by a ‘new’ member. This marks certain limits, but each

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individual with their guiding faculties will develop in that scheme given its own adaptation, employing particular settings. This way of understanding the human being is not without moral implications, if we consider the ethics of health services (bioethics). Here ethics is identified not only through making the dignity of the human person a duty, or based on a calculation of advantages and disadvantages to achieve the greatest possible happiness for all, but rather, in this approach ethics finds its purpose in highlighting the fact that the human being has to be something, and what that is is constantly being questioned (Acevedo 2006). We can say that ethics consists of operating a hermeneutics of existence, of what seeks to be said through this call of conscience, which is not a superior authenticity but rather existence itself that speaks to the human being. It follows that the existential dimension of the phenomenological model applied in the approach aiming at the inclusion of people with disabilities is to create a commitment on the part of health service providers towards the liberation of people with work challenges as a result of exploring the occupational meaning (Larivière and Quintin 2021), assertive and self-determined social functioning. Existentialist thinking offers a complementary approach, which improves the foundations of the profession focused on validating the rights of people with disabilities and supports two main principles: 1. human beings as self-made beings, always in the process of becoming and 2. emotions and feelings as foundations of being-in-the-world (Babulal et al. 2018). To adopt an ethical posture is to promote the full freedom of others, participating in their liberation. Human care has no meaning other than promoting a common project with human freedom as basis. Interestingly, it is when human beings finds themselves in a situation of having a disability, that they turn to themselves and to their freedom to lead an authentic life according to their own options and the meaning that they want to give to their own life.

4.3 Case Presentation Camila is a 12-year-old girl (female) with a moderate intellectual disability, who goes to the health centre of her commune with her mother, where the treating doctor maintains a negative and discriminatory attitude towards her, since he questions her mental health and that of her family, pathologizing her condition and refusing to give her the care she requires, making value judgments on the girl and her mother given that he tells them that the girl should be called by a man’s name. For this reason, both get very upset and must, therefore, be assisted by other professionals from the centre (occupational therapist and psychologist), who recognize the incorrect practice and attitude of the doctor, and consider exposing him for what he did.

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4.3.1 Identification of Problems, Bioethical Principles and Values in Conflict In the present case, non-compliance with the four bioethical principles can be noted (Ferrer 2003), such as: • Autonomy principle: in which the girl’s decision to be called by her social name is not respected, revealing a lack of autonomy on her part as well as that of her mother, who likewise asked for her daughter to be called by the indicated name. • Nonmaleficence: In relation to this principle, that states that no harm should be caused to the users, there is evidence of mistreatment of both the girl and her mother, leading to a violation of their rights and to the questioning of their mental health. • Charity: This principle refers to acting for the benefit of users. In the analysed case, it is evident that the doctor did not act in the appropriate way, since he pathologized the girl’s gender identity, and accused the mother of negligence for allowing her daughter’s gender expression, denying adequate care and quality to the user, that demanded that all their rights were respected and protected. • Justice: which is clearly not being respected, since Camila cannot access a basic right that is health, because the doctor is depriving her of her right to receive care and of ‘healing’ her discomfort.

4.4 Deliberation Right to health: In relation to the mentioned case, we believe that the right to health has been interfered with, as evidenced by the treatment of the doctor towards the user. The right to health entails a civic and human value, so the professional had to make use of his skills, leaving aside his own judgments and deliver adequate and dignified care, without neglecting the well-being and right to receive care in Health. Gender identity: Regarding the analysed case, it is evident that the gender identity of the 12-year-old girl was not respected, violating her rights and challenging her mental capacity, apart from not respecting her mother in the situation. Discrimination: Discrimination against the girl is practiced by the doctor by not respecting her gender identity. The same happens with the user’s mother, given that this professional recommended that both should see a psychiatrist, as a way of pathologizing the girl’s identity and creating value judgments of these two people.

4.5 Considerations for the Application of Informed Consent Informed Consent Considerations:

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• The consent will be addressed to the mother of the user, since the latter is a minor. • In the consent form, when there is reference to the user, it must be made with her social name, in this case, ‘Camila’, and not with her birth name. • The consent will be read and explained slowly to the user’s mother, asking her if she understands what is being said. Emphasis will be given to the most important parts of the document. • If the mother of the user does not have a signature, she will be provided with an inkwell for her to sign with her tactile fingerprint or she will be asked to only write down the number of her identity document.Considerations for assent: • An assent form will be provided to the user, considering that she is a minor (Zavala 2002). • The assent form will be addressed with the social name of the user, in this case ‘Camila’. • Her gender identity will always be asserted and referred to with the pronoun ‘her’. • The language of the assent form will be accessible and easy to understand, considering the age of the user. • The user must assent and agree with each point that is explained to her.As for the adaptations for both documents, they will be: • The mother of the user will be asked if she gives the authorization, and will be recorded when signing the consent, as well as her daughter when signing the assent form. In addition, visual material will be provided, such as a Power Point presentation or images where the same of forms of consent and assent are written in order to maintain the attention of both. • Possible environmental modifications will be taken into account, such as adequate lighting. Also, there needs to be as little environmental noise as possible and the environmental temperature is to be regulated (i.e., neither too hot nor too cold), without objects that hinder movement or that may cause damage, etc. • An environment of trust between the professionals, as well as between mother and daughter, will be promoted. • Finally, in the context of the COVID-19 pandemic, it is essential to respect the capacity of people allowed in the room, wearing masks and complying with the established health protocols, protecting the health of everyone involved. • Camila’s participation benefits from the social environment, access to a dignified and significant participation in the occupations of daily life and in her health choices (Palomer 2009).

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4.6 Ethical Guidelines for Community Intervention and Social Network As seen in the bioethical orientations described above regarding interventions in people’s health, it is important to educate the professionals who work in centres such as the one Camila visited, enlightening them on and reminding them of the rights and duties of the patient, their responsibility as professionals, and giving talks regarding sexual education, gender identity, sex, etc. Also, teaching them the importance of learning how to treat users with respect and equality so that all people may be granted the same access and right to health. In addition, in the context of health centres, families of trans children and adolescents who belong there must be educated, so that they know their rights and duties as patients and learn how to act in situations of discrimination. On the other hand, it is essential to provide professionals with the necessary knowledge about bioethical principles that should guide their practice, and show them the different degrees of relevance they hold in different situations, given that as professionals who work with people, they must be trained to deal with various circumstances that might arise, always respecting the beneficence, non-maleficence, autonomy and justice of the users they serve, without distinction.

4.7 Aspects of Legality in the Context of Chile Law No 21,120 of 2018, article number 4, letter b recognizes and protects the right to gender identity, where letter b of this article focuses on recognizing and identifying it in accordance with gender expression in political and private instruments that prove their identity with respect to name and sex. In addition, it states that computer data or any other instrument through which people appear in official records must match that identity. This law is important in this case since the health professional did not want to provide health care to his patient, and was not willing to call her by her social name, so it is possible to notice that the doctor was undermining her rights as a citizen. Decree No 41 Regulation on Clinical Records (December 15, 2012), which refers to the provisions that regulate the conditions of preparation, content, storage, administration, protection and elimination of the clinical records of people who receive health care. Taking into account the content of this decree, it is clear that the doctor is wrong when he refuses to assist and to deliver proper care to Camila, writing her birth name and gender on her medical record, as opposed to her gender identity, which should prevail. Law No. 20,584 of 2012, Its purpose is to regulate the rights and duties that people have regarding their health care. It states that every person has the right, regardless of the person who provides the care, to protection and recovery of their health and to rehabilitation, and the care provided is to be given in a timely manner

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and without arbitrary discrimination. In this specific case, it is important to assert this right of Camila, who even though is a minor, deserves respect and equal access to health providers, whether public or private.

References Acevedo, Jorge. 2006. Ética originaria [en Heidegger] y psiquiatría. https://www.academia. edu/5769609/%C3%89tica_originaria_en_Heidegger_y_psiquiatr%C3%ADa Babulal, Ganesh M., Selvaratnam, Arun, and Taff, Steven D. 2018. Existentialism in occupational therapy: implications for practice, research, and education. Occupational Therapy in Health Care. https://www.tandfonline.com/doi/full/10.1080/07380577.2018.1523592. Ferrer, Marcela. 2003. Equidad y justicia en salud. Implicancia para la bioética. Acta Bioethica 9 (1): 113–125. Frankl, Viktor. 1989. El Hombre en busca de su Sentido. Barcelona: Editorial Herder. Larivière, Nadine, and Jacques Quintin. 2021. Heidegger and human occupation: An existential perspective. Journal of Occupational Science: 1–11. Ley No 20,584. Regula los derechos y deberes que tienen las personas rn relación con acciones vinculadas a su atención en salud (24 April 2012). Ministerio de Salud. Diario Oficial de Chile. Ley No 21,120. Reconoce y da protección al derecho a la identidad de género. (10 December 2018). Ministerio de Justicia y Derechos Humanos. Diario Oficial de Chile No 3088–32. Palomer, Leonor. 2009. Consentimiento informado en odontología: un análisis teórico-práctico. Acta bioethica 15 (1): 100–105.

Part II

Moral and Legal Agency

Chapter 5

Argentina’s Mental Health Law: Sociocultural Questions Regarding the Normative Framework Marisa Adriana Miranda

Abstract  This chapter presents a critical reading of the legal treatment given to the mentally ill in Argentina based on a sociocultural analysis, but not without an indispensable hermeneutical examination of the law, which has been in place for a little over a decade. Recovering the thesis of John Rawls, this paper especially turns at those who possess characteristics that exclude them from the world of the ‘normal’. These ‘abnormal’ human beings, called padecientes mentales (mental health sufferers) since the passage of the National Law on Mental Health and Addictions in 2010 as Act 26657, nevertheless continue to be objects of social disciplinary power. A power that, although somewhat diminished by the current law, makes it necessary for broad protection to be directed at subjects who undergo a double stigmatization, as is the case of madwomen, among others. From this perspective, a somewhat biased response in the regulatory norms can be observed, a circumstance that becomes particularly clear in relation to gender, on which the chapter will focus its attention. Keywords  Argentina · Mental health law · Mental illness · Social disciplinary power · Gender

5.1 Introduction: Legal Norms Faced with the Imprecise Borders of Mental Illness In general, the spectrum of health-disease is acknowledged to be a territory fraught with questions, questions that intensify in relation to what are known as mental illnesses. Keeping in mind the complexity that comes with any attempt to regulate the This work was carried out in the framework of the PIP 11220200100407CO (CONICET). M. A. Miranda (*) National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina University of La Plata (UNLP), La Plata, Argentina © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_5

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mentally ill, the purpose of this text is to propose certain issues connected to the incarnation of the normative framework, considering in particular the subjects of rights who are protected. This chapter will examine the legal treatment, established by the normative framework in mental health, of people whose stigmatization for their madness acts synergistically with other stigmatizations, going beyond just that of madness. Facing such a panorama are those who are always adjectivized: the mad and sexually dissident (queer or any other type of heterodox sexuality), the mad and delinquent, the mad and HIV+, that is, those who are in any way both mad and ‘maladapted’ – even those who are simply mad are poor – and whose behaviours are looked down upon by society. However, there are also types of madness that are ‘permitted’, such is the case with a number of artists whose ‘madness’ is admired and considered to offer a qualitative contribution to their professional performance. In this case, far from seeking to denote mental illness, the term is used with the manifest intention to exalt those who possess it. In this context, it is imperative to reflect on why the same term is used to positively value someone while it is at the same time considered a negative trait in other subjects. What is the condition that makes it an admirable characteristic in some and deplorable in others? Why is that in evidently dissimilar situations our culture makes use of the same term? We can speculate that this entails somehow distinguishing between the affable mad and the formidable mad (or, thinking of a disciplined society, the permitted mad and the prohibited mad), even when the first are not truly authentically mad, that is, crazy mad. In effect, these first fall closer to a rebelliousness accepted by the society than to a pathology, and in this way are well distanced from madness as a disease. However, the second group, the formidable mad (or prohibited mad), constitute a group deemed to be threatening, whether for their aggressiveness (we should recall the existence in older normative frameworks of the figure of the raging lunatic), or for their disassociation with the real world. In this way, the fears of the ‘normal’ take shape, making it necessary for the full force of the law to be deployed. A law that frequently expresses a certain undervaluing of these humans, incorporating strategies to exclude from the visible, desirable world that which tarnishes it. And so, what to do with the subject who belongs to the universe of the undesirable – the formidable mad or the prohibited mad or simply the mad – becomes a challenge to be taken on by the normative bodies of the state. It is known that the itineraries followed by the powers that manage madness1 have since ancient times involved punishment, with the State response being the instrumentation of a number of policies of invisibilization and segregation (that is, segregation to ensure invisibilization). Among these policies, likely the most emblematic is that of confinement in asylums which, far from facilitating a cure (considered impossible in a number of different spheres), constitute true spaces of exclusion. In this sense, it should be made clear that the hospitalization ad infinitum of people with mental illnesses was less about their protection and more about  In this sense, it is necessary to once again revisit the classic work of Foucault (1961). For an interpretation of Foucauldian thought on the matter, among many other excellent texts, see Gros (2000). 1

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defending society from the abnormal behaviours of asocial individuals, based on a paradigm of normality constructed by the psychiatric biopower instrumented through different legal devices.2 This question underlying what to do with the mad has also been present in Argentina since its conformation as a modern Nation-state in the second half of the nineteenth century. If madness is sickness, then care and a possible cure is what is required. If madness is criminality, then jail is in order. The problem is precisely that the mad are located in a borderland and society has not known where to put them. They do not have a place; they are in a non-place. Confinement in neuropsychiatric hospitals is far from a utopic ideal; rather, it is a dystopic reality. In them, the mentally ill are secluded, but not entirely; they are isolated, but it is assured they maintain contact with the society in which it is supposed they will one day reinsert themselves. Overmedication is also common, with the pretext of them recovering their lost calm. They exist, but ‘it is as if they did not’. From their place in the shadows, they are unnoticeable, they cannot be seen. And to bolster this strategy of concealment, the allied functioning of the medical-psychiatric and legal bodies is undeniably imperative. Nevertheless, towards the end of the last century, that is, a little over two decades ago, segregation via confinement lost a certain relative weight largely thanks to the strengthened presence of the desmanicomialización or anti-asylum paradigm. It should be highlighted, however, that the asylum is often substituted by excessive or even extreme medicalization.3 It is also relevant to point out that modern psychiatry appears to be almost obsessively focused on obtaining precise diagnoses, characterised fundamentally by a hyper-specific range of pathologies, described in an extremely detailed manner in the DSM,4 even when treatment almost aways falls to a reduced number of psychopharmaceuticals (Galende 2017). There is no doubt that the current law in Argentina has worked toward integration into the aforementioned inclusive paradigm, even when, as we will see, it also demonstrates certain fissures (or unresolved issues) that ought to be examined.

5.2 Madness and the Urgent Necessity for an Approach with a Gender Perspective The way madness is approached is marked by gender stigmatization, in which the mentally ill person, if she is a woman, is the subject of a double, unresolvable affront: that of her mental illness, on one hand, and that of being a woman, on the  For an excellent examination of the treatment of madness in Europe, see Fuentenebro et al. 2003. The works of Rafael Huertas are also an indispensable reading on the subject, especially Huertas (2012, 2014). 3  The prolific work of Sandra Caponi, a researcher of Argentine origin living in Brazil, should be highlighted, some of the results of which can be found at: Caponi et al. (2016) and Caponi (2021). 4  The Diagnostic and Statistical Manual of Mental Disorders, a tool that has been published by the American Psychiatric Association for a number of decades. 2

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other. Based on the widely acknowledged situation of inferiorizing inequality that has characterised (and differentiated) women and men as a matter of structural dimensions that crosses into the legal and health fields, gender and mental health converge to reinforce the fabric of patriarchal violence (Miranda et al. 2020). Along these lines, we uphold that the stigmatization and subsequent exclusion of madwoman should be read in terms of gender, a circumstance that repeats itself even in the present day (Femenías et al. 2009, p. 44). To this can be added the existence of undeniable and numerous forms of violence that make women victims of the States and institutions, as all advances gained by women, even today, are in general seen as a threat to the privileges previously only conferred to men (López et al. 2017). From this perspective, it is acknowledged that the devices of power (medical-­ legal-­familial) exert social control through their discourses and practices, prescribing behaviours considered normal and penalizing those considered deviated or pathological. In effect, the health system, the legal system and the family operate as disciplinary institutions that structure the social terrain and guarantee mechanisms of reproduction (Foucault 1975). From there, the pattern of normality/abnormality is reproduced in the hegemonic medical model that centres in ‘the masculine’ that which is normal, healthy and mature and in the ‘feminine’ that which is abnormal, pathological and unfinished. This view is functional to the pathologization and disqualification of women, perpetuating at the same time the invisibilization of the mental pathologies of men. There is vast evidence of the medicalization of certain issues inherent to (or associated with) the life of women; in this way, the large share of mental treatments falls upon women as compared to men (Bonino 2000). In this sense, the existence of a cultural conception can be recognized, related to a double consideration of the incapacity of women: as women and as ‘madwomen’. This particularly feminine concept of madness encompasses tropes such as: the suicidal, the saint, the hysterical, the old maid, the witch and the bewitched, the nun, the possessed, the enlightened, the bad mother, the stepmother, the child killer, the prostitute, the caste, the lesbian, the menopausal, the sterile, and the abandoned, among others (Lagarde y de los Ríos 2005, p. 687). A biologicist character penetrates in this way the legal model in which the law operates as an institution of control and discipline exerted on the lives of women (their psyches and their bodies), reinforcing what is the implicit end of this expression of biopower: upholding the principles of the patriarchy (Foucault 1976). Similarly, in relation to the traditional family model, still in force in a number of western countries, it should be highlighted that it is here where the generic condition of woman can be best visualized in the role of wife, mother, homemaker, confined to procreation and the rearing and education of children. The family institution, through its socializing function, contributes to the definition of the social role of women, based, in addition to the reproductive function, on the conception of motherhood as an inescapable biological mandate (Duby and Perrot 2000, p. 127–132). In this way, the association of the term ‘woman’ with attributes such as sensitivity, domesticity and maternal instinct contribute to reaffirm this stereotype through the reinforcement of the notion of ‘female nature’. Hypothetical physical weakness and

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sensitivity is posited in opposition to the (obviously also hypothetical) rationality and strength of males, in this way legitimizing the allocation of women to the domestic sphere and of men to the public sphere. Especially in Argentina, it is worth remembering that in every political proposal related to the family there is an underlying conception of femininity and of the ‘female sphere’ (Torrado 2012). In effect, whether in relation to the home, the workplace, citizenship or maternity, in the name of the homeland (Miranda 2020) the ideal of the female condition and the norms that regulate it are crystalized, making it necessary for women, in fulfilling these obligations, to internalize these ideational configurations and display corresponding behaviours. A passage through these contexts allows for the identification of the discourse regarding women that underlies each and that is reproduced in related practices. In this way, a hegemonic social discourse is shaped, one that seeks to hide the logics of male domination upon which the discourse is based, perpetuating inequality and discrimination. It is therefore necessary to reflect upon the concept of social discourse as a product of a sociohistorical and cultural construction, considering within them generic systems, topical repertoires, that organize that which is able to be said, narrated and given as opinion, and that assure the division of discursive labour. They constitute a mechanism that operates to unify and regulate, imposing dogmas, fetiches and taboos; this mechanism is therefore an effective instrument of social control and discipline (Angenot 2010). This basic presupposition organized by the culture is connected to the underlying social labelling of women as ‘mad’ or, under the best of assumptions, as prone to madness, a charge that acts as a threat to the patriarchal order in the consolidated model of social relations. And one can of course consider whether this same society does not itself generate violence and promote madness. In this context, at present, the ‘madwoman’ represents a certain generic madness of all the women who go mad because of their obedience and fulfilment of the feminine ideal or because of their transgression, lending force to the affirmation that “women go mad because of how womanly they are, and they go mad because they cannot fully be a woman, or in order to not be one” (Lagarde y de los Ríos 2005, p. 40). This (generic) madness of women can be read through their sexuality and their relationship with others, in which direct relationships of dependence, submission and inferiority with respect to men are expressed. Captive in bodies ‘for others’, be it for procreation or eroticism, women are defined as incomplete entities or territories available for occupation and domination. Although the degree to which and the manner in which each woman experiences her generic condition varies, it is evident that the women who deviate from the feminine ideal imposed by this model are indefectibly labelled as sick, incapable, strange, mad. The media has had a significant contribution in this sociohistorical construction, in particular since the twentieth century; the sexual-reproductive role of women was buttressed by ads, novels, magazines, soap operas, and so on, directed at the modern woman. In them, the expression cabecita loca (literally a woman who has a ‘crazy little head’) – note, once again, the appearance the idea of madness – was employed to denote women who challenged the female archetype or rejected

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the traditional role assigned to them and sought to venture in to other areas of the public sphere (Barrancos 1999). With just this brief panorama, the wide reach of the term ‘mad’ can be observed, denoting something more than a disorder of the psyche and transcending to the moral and sexual order of women. Therefore ‘madness in women’ can frequently be understood as the product of social situations that can only be recognized through an epochal perspective and explained though gender inequality. Women’s madness therefore puts into evidence the structural dimension of the issue, in which the ‘androcentric worldview’, in the sense of Bourdieu, feeds and justifies the relationships between genders. Along with Bourdieu we can ask ourselves about the mechanisms responsible for the ‘dehistoricisation’ and the ‘eternalisation’ of the structures of sexual division. And, based on the exploration of symbolic structures of what he calls the ‘androcentric unconscious’, it is possible to explain a certain ‘hypnotic power’ that transforms historic contingencies and cultural arbitrariness into the ‘natural’. In effect, the masculine social order works as an immense symbolic machine that perpetuates male dominion, expressed in the sexual division of labour and the sexual organization of space; in the distribution of time, marked by production for men and by gestational cycles for women; and in sexual relations. In this way, all of these arbitrary sexual divisions of the social world are perceived as coming from the ‘order of things’ and are naturalized. Therefore, “a relationship of domination” is legitimized “by embedding it in a biological nature that is itself a naturalized social construction” (Bourdieu 2005, p.  37). In alignment with this notion, it should be recalled that all structures are “always, in the end, hierarchical. They can contain the possibility of inversion and permutation, but never symmetry” (Segato 2003, p.  56–57, own translation); gender inequality is inherent to the domain of the patriarchal structure. In this sense, it is necessary to identify the hegemonic social discourse regarding women encrypted in the social institutions so as to help reveal the logics of masculine domination that the discourse enshrouds (Angenot 2010). And from there, to recover the question that motivates inquiries like the present: Why talk about gender and mental health? (Lira and Luciana 2014). Based on the status quo that sustains the situation of inferiorising inequality of women in relation to men, we recover the contributions of John Rawls and François Dubet regarding the ‘injustice’ of equal treatment in situations that, for a number of reasons, are different. Consider Rawls’s graphic example of the need to ‘level the playing field’ before a match, meaning that before a game one of the players is in a situation of evident inequality.5 We should recall that the equality of position and the equality of opportunities constitute the two great pillars upon which the primary conceptions of social justice in contemporary thought are based; it should be emphasized that through them it is proposed that  Regarding these theoretical references, it is crucial to recall the wide recognition of Rawls as a point of inflection in liberal and democratic thought, serving as a theoretical base for current debates regarding multiculturalism, identity politics, political difference, theories of discrimination and new theories of citizenships. See, for example, Rodríguez Zepeda (2004). We should recall that Rawls’ work, A Theory of Justice, was originally published in 1971 (Rawls 1971). 5

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the fundamental contradiction present in current democratic societies between individual inequality and social inequity can be resolved, or at least relieved (Dubet 2011).

5.3 Toward (Biased?) Inclusion: Reflections on the Recent Argentine Legislation As was previously highlighted, female madness denotes something much more complex than a mental health disorder, additionally revealing an association between hegemonic medical power and patriarchal power. In effect, the pyschiatrization of those women who resist or are unable to respond to the mandates that gendered roles impose upon them is a resource that the patriarchy possesses to normalize and discipline female bodies, medicalizing their indignation and suffering. Nevertheless, women’s madness is understood from a critical perspective as a legitimate way of confronting reality and not as a symptom of mental disorder. In this way, the cultural and social backdrop of this issue implies, as a start, depathologizing the responses of women to trauma and oppression, that is, to stop considering women an ‘object’ of psychiatric power. Given the stigmatization that falls upon ‘alienated’ women, this objectification constitutes a product of the standards of ‘normality’ constructed by and for that particular social structure. In this context, the disciplinary power of psychiatry exerts itself upon bodies – of men, but fundamentally, of women – silently, exacting obedience and submission in such a way that it appears to emerge as the constant will of the individuals themselves (Contreras Tapia 2015). This becomes evident, for example, in confinement in total medical institutions (hospitals or asylums), in asylum discourses and practices, in which the Foucauldian relation of subjection appears naturalized, normalized. Once these power relations have been established, they interact and become functional to the idea of correcting a ‘sick society’ while reproducing the system of masculine domination. Through the discipline, control and coercion of women’s bodies, an almost mechanical restraint and constant subordination is achieved that keeps women medicalized and convinced of their own madness. This disciplinary character of psychiatry is well analysed by what is known as the ‘antipsychiatry’ movement, which emphasizes the existence in different historical periods of different mechanisms of repression and domination (Szasz 2005). In this sense, psychiatric power can be compared to that of the inquisition, the psychiatrist to the executioner, the ‘mad’ to the heretic, and the ‘madwoman’ to the witch, the possessed, the sinner; both are stigmatized by the society as ‘dangerous’. In effect, the repressive system, to conserve its stability and permanence, extracts from its own body the deviated ‘other’ that constitutes a threat, with undoubtable aspirations of assuring itself immunity (Esposito 2002). In this same vein, it has been affirmed that psychiatry constitutes a phenomenon of social segregation, an invention of modern society; in the same way that, in the Middle Ages, the priests fabricated heretics, today doctors, as the new guardians of social morals and behaviour

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have fabricated ‘madwomen.’ The fabrication of madness is a social construction that has a stabilizing effect on society and regulates the actions of individuals, countering behaviours that are accepted and embody normalcy with others than are unacceptable, bringing about drastic consequences such as stigmatization, rejection, persecution, marginalization, and confinement, among others. This sociocultural reading of women and madness, which extends beyond (and includes) the Argentine context, is indispensable in drafting an interpretation of the current legal norms. The Mental Health Law (Act 26657) was sanctioned in Argentina in 2010 implemented through Decree 603 in 2013. While this legislation had undeniable aspirations of inclusion of the mentally ill (referred to as mental health ‘sufferers’ since the passage of the law), it nevertheless continues to cling to the dominant paradigm of masculinity. The legislative debates that gave rise to this first comprehensive legal framework in the country regarding mental health began in 2009. The project was approved with ample consensus in both legislative chambers, supported by the Health Commission having previously issued a favourable opinion of the bill. The Commission based its opinion on the World Health Organization’s Constitution, in its contemplation as a central international principal the enjoyment of the highest attainable state of health that can be reached by a person, additionally constituting a fundamental right. Nevertheless, upon deconstructing the legal articles and the decree establishing the law’s implementation, the lack of attention to the factual distance between the madwoman and the madman is surprising; more specifically, what stands out is the legislative silence on the matter, as if these differences did not exit. Act 26657 focuses on the (undeniable) need for an interdisciplinary approach for those who suffer a mental illness, as well as the importance of family support for maintaining affective relationships. Happily, from this starting point, mental health care went in an anti-asylum direction as a response to the extremely pertinent criticisms made regarding these total institutions. Nevertheless, the normative framework lacks any specific mention of women as a vulnerable group to be taken into special consideration in the formulation of public policies in mental health. The law, constructed on the base of a presumed equality between men and women, leads to the idealization of an inexistent reality. This explains, for example, the lack of any mention whatsoever of ‘gender’ and related situations in practice, as well as the lack of inclusive language; indeed, the text makes use of the masculine universal (el paciente, el professional, el enfermo). Nevertheless, there are a few articles of the law that merit closer attention, as they leave open the option of offering a certain protection to women, facilitating in this way a hermeneutics that observes the required gender perspective. For example, article 3 sustains the recognition of. (…) mental health as a process determined by historical, socioeconomic, cultural, biological and psychological components, the preservation and improvement of which implies a dynamic of social construction tied to the fulfilment of the human and social rights of all people,

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based on the presumption of their capacity. At the same time, the article highlights the impossibility of truly carrying out a diagnosis in mental health that takes into account political and socioeconomic status of a person, their inclusion in a particular cultural, racial or religious group, as well as the familial and work demands placed on them, their lack of conformity with or adaptation to the dominant moral, social, cultural, political or religious beliefs in the community in which they live. Nevertheless, this article would have been improved by including details still absent to this day. Indeed, that article’s recognition of the components that make up mental health, including cultural and biological aspects, lead us to think about the way in which women are conceptualized, treated and categorized in their own minds as well as by men and the State. Taking into account the way in which women are conceptualized by society and the rights that should have been recognized and enforced could improve the ‘social construction’ tied to the fulfilment of human and social rights that the article references. At the same time, article 7 of the Mental Health Law contemplates the State’s recognition, in relation to the people with mental illness, of such rights as. a) the right to receive comprehensive and humanized health and social care, based on free, equal and equitable access to necessary services and resources, with the objective of assuring the recuperation and preservation of health; b) the right to know and preserve one’s identity, groups of belonging, genealogy and history; c) the right to receive care with scientific foundations adapted to ethical principles (…); l) the right to receive personalized treatment in an adequate environment that protects the one’s privacy, always being recognized as the subject of rights, with full respect for one’s private life and freedom of communication.

It is necessary to stop here to examine the patient-professional relationship, emphasizing the consequences it has in people’s public and personal lives. In our society, a professional’s conduct is imputable (legal negligence, imprudence or inexperience) with impacts in the civil and penal codes. Responsibility is a primary value within the activity of professionals, especially health professionals, which requires that they make decisions in accordance with such criteria and general principles as respect for autonomy, beneficence, nonmaleficence and distributive justice in particular cases or situations (Sánchez Vázquez et al. 2015, p. 101). It is precisely based on this professional role that the autonomy of female service users has weight, given that, depending on the freedoms given to a woman in treatment, the autonomous agency of the patient will emerge, which in turn produces versatility of her navigation of what is an often-threatening environment as well as the ability to construct new norms or forms of organization in her encounter with others. The repercussions of this aspect in the subjectivity of women are evident. At the same time, the terms ‘equal and equitable’ from section a., in conjunction with sections c. and l., are clearly insufficient, given that equal health access among women and men does not occur when it is known that a certain preferential access exists for men. We should ask ourselves, then, whether it is correct to affirm the concrete possibility of personalized treatment without a gender perspective. Since it is ‘not the same to be a madwoman as a madman’, it is imperative that a normative framework like the Mental Health Law offer women positive differential treatment

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(in the sense indicated by Rawls), as subjects whose rights are doubly violated.6 Only with this framing will the exercise and of rights be guaranteed in praxis and proper checks be put in place to facilitate women being placed in equal standing with respect to men. Beyond the obvious value of the law enacted in Argentina, it is nevertheless necessary to fault, in the instruments that it offers to design public mental health policies, the lack of contemplation of the culturally established diversity among men and women that add to mental illness another stigmatization, with undeniable repercussions in the rights guaranteed. Some rights of this sort were in a way recognized at the end of 2021, outside of the purview the Mental Health Law, although they form part of protective context sought by that law. We are referring to the modification of another law (26,130), sanctioned in 2006, prior to Mental Health Act, that recognized people’s right to access to tubal ligation (for women) and vasectomies (for men), when expressing their desire to do so and giving their informed consent. Nevertheless, the law established that “when the person in question has been declared legally incapacitated”, authorization from their legal representative was an unavoidable requirement (art. 3). After the numerous and just demands coming from groups involved in the defence of Human Rights, in December 2021, this article was modified through Act 27655, establishing that. (…) all people with disability, without exception, have the right to offer their informed consent to access surgical contraceptive interventions, on their own and in the same conditions as all other people (…). In no case is legal authorization required. People with disability have the right to receive information regarding the practices regulated by this law in means and formats accessible to them and to solicit systems of support and reasonable adjustments that allow them to give their consent autonomously. Safeguards should be put in place to avoid substitutions in their decision-making. If the person in question has had their capacity restricted by a judicial ruling and the restriction makes no reference to the exercise of the right extended by the present law, the person may offer their informed consent without impediment. If the ruling of restriction of capacity mandates support in exercising the right extended by the present law, informed consent must be provided by the disabled person with the assistance provided for in the system of support of article 32 of the Civil and Commercial Code (art.2).

From this point forward, the sterilization of people with disabilities will only be able to be carried out when they request it, and with information corresponding to the decision they make. While this issue impacts both sexes, the impact is greater for women, who, despite their ‘madness’, today have total freedom in relation to their procreational decisions.

 For an analysis of gender and madness with a historical and present-day perspective, see Miranda (2019). 6

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5.4 Conclusion As a final reflection it should be emphasized that both that which is explicitly stated and that which is silenced in the National Mental Health and Addictions Act in Argentina, in addition to how it was debated in the National Congress and how it was later sanctioned, can be explained from a paradigm denominated informationalist (masculinizing, in this case) (Femenías et al. 2009).This paradigm posits a context in which a selection and consequent segregation of voices, codes and discourses is generated, benefiting those who have power and those who are able to make themselves heard. It can therefore be maintained that the legislative chambers made use of a predominant discourse, failing to consider the type of social integration promoted by the supposed equality of access. It is worth asking, therefore, whether the invisibilization of subordination is a mechanism of the global paradigm itself (Femenías et al. 2009, p. 57). Within this paradigm, the silencing and invisibilization of certain voices is a way to reinforce subordination. The factors of power that condition the cultural framework are those that decide the information that should circulate and establish the implicit and explicit language of that symbolic order. In this way. The patriarchy utilizes the force of ideology, of the discourses of its word to generate a mystique surrounding femininity, motherhood, and compulsory heterosexuality, denying or deauthorizing the words generated outside of this pact, outside of this brotherhood. (Femenías et al. 2009, p. 56). While we celebrate the advances in a process of inclusion generated by the National Mental Health and Addictions Act, it is also crucial to observe that the law is not fully capable of supporting a favourable resolution regarding equal legal treatment for madwomen. It is a good and necessary law, but it is insufficient. An integrative hermeneutics, with the full span of the normative framework aimed at the rights of women, is therefore crucial.

References Angenot, Marc. 2010. El discurso social. Los límites históricos de lo pensable y lo decible. Buenos Aires: Siglo XXI. Barrancos, Dora. 1999. Moral sexual, sexualidad y mujeres trabajadoras en el periodo de entreguerras. In Historia de la vida privada en la Argentina, ed. Fernando Devoto and Marta Madero, vol. 3, 198–225. Buenos Aires: Taurus. Bonino, Luis. 2000. Varones, género y salud mental: deconstruyendo la ‘normalidad’ masculina. In Nuevas masculinidades, ed. Marta Segarra Montaner and Angels Carabí, 41–64. Barcelona: Icaria. Bourdieu, Pierre. 2005. La dominación masculina. Barcelona: Anagrama. Caponi, Sandra. 2021. Sobre la llamada revolución psicofarmacológica: el descubrimiento de la clorpromazina y la gestión de la locura. História, Ciências, Saúde – Manguinhos 28 (3): 661–683.

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Caponi, Sandra, Vázquez Valencia, María Fernanda, and Marta Verdi, eds. 2016. Vigiar e medicar. Estratégias de medicalização da infância. San Pablo: Liber Ars. Contreras Tapia, Javiera. 2015. Enajenadas, Poder y Locura. Disciplinamiento de los cuerpos de mujeres internas en la Casa de Orates de Santiago y sus memorias psiquiátricas. Tesis para optar al grado de Magíster en Estudios de Género y Cultura en América Latina. Santiago de Chile. Universidad de Chile Facultad de Filosofía y Humanidades. Dubet, François, 2011. Repensar la justicia social. Contra el mito de la igualdad de oportunidades, Buenos Aires: Siglo XXI. Duby, Georges, and Michelle Perrot. 2000. Historia de las mujeres. Vol. 5. El siglo XX. Madrid: Taurus. Esposito, Roberto. 2002. Inmunitas. Protezione e negazione della vita. Turin: Giullio Einaudi. Femenías, Maria Luisa, Soza Rossi, and Paula. 2009. Poder y violencia sobre el cuerpo de las mujeres. Sociologias 11 (21): 42–65. Foucault, Michel. 1961. Folie et déraison. Histoire de la folie à l'âge classique. París: Plon. ———. 1975. Surveiller et Punir: Naissance de la prison. París: Gallimard. ———. 1976. Histoire de la sexualité. París: Gallimard. Fuentenebro, Filiberto, Huertas García-Alejo, Rafael, and Valiente Ots, Carmen (eds.). 2003. Historia de la psiquiatría en Europa. Temas y tendencias. Madrid: Frenia. Galende, Emiliano. 2017. Conferencia magistral dictada en el Primer Congreso Provincial de Salud Mental y Adicciones. Tandil, 11–13 May. Gros, Fréderic. 2000. Foucault y la locura. Buenos Aires: Nueva Visión. Huertas, Rafael. 2012. Historia cultural de la psiquiatría. Madrid: Libros de la Catarata. ———. 2014. La locura. Madrid: CSIC-Los Libros de la Catarata. Lagarde y de los Ríos, Marcela. 2005. Los cautiverios de las mujeres: Madresposas, monjas, putas, preas y locas. México D.F: UNAM. Lira, Ramos, and Luciana. 2014. ¿Por qué hablar de género y salud mental? Salud Mental 37 (4): 275–281. López, María Noelia, Jacqueline Torres, Weber Suardiaz, and Clara. 2017. Debates en el campo de la salud mental. In Práctica profesional y Políticas Públicas. La Plata: EDULP. Miranda, Marisa, ed. 2019. Las locas. Miradas interdisciplinarias sobre género y salud mental. La Plata: EDULP. ———. 2020. Madre y Patria. Eugenesia, procreación y poder en una Argentina heteronormada. Buenos Aires: Teseo. Miranda, Marisa, Andrea González, Bega Martinez, and Renata. 2020. Mujeres-‘Locas’: protección jurídica ante violencias de género intrafamiliares. In Todo lo que está bien no es lo que parece. Acceso a la justicia en casos de violencias de género y salud mental, Manuela G. González, 325–352. La Plata: EDULP. Rawls, John. 1971. A theory of justice. Cambridge: The Belknap Press of Harvard University Press. Rodríguez, Zepeda Jesús. 2004. El igualitarismo radical de John Rawls. Isegoría 31: 95–114. Segato, Rita. 2003. Las estructuras elementales de la violencia. Ensayos sobre género entre la antropología, el psicoanálisis y los derechos humanos. Buenos Aires: Prometeo-Universidad Nacional de Quilmes. Szasz, Thomas. 2005. La fabricación de la locura. Barcelona: Kairós. Torrado, Susana. 2012. Historia de la familia en la Argentina Moderna (1870–2000). Buenos Aires: De la Flor. Vázquez, Sánchez, María José, Hector Blas Lahitte, Ortiz Oria, and Vicente. 2015. Bioética y Salud Mental: reflexiones sobre la afección y la responsabilidad en la relación profesional-­ paciente. Revista Latinoamericana de Bioética 15 (2): 96–107.

Chapter 6

Legislation and Practices of Psychiatric Institutionalization in Brazil: A Foucauldian Interpretation of Barbacena’s Holocaust Ana Paula Barbosa-Fohrmann

and Anna Caramuru Pessoa Aubert

Abstract  The Brazilian Holocaust was a tragedy that took place at the Hospital Colônia de Barbacena between the 1930’s and the 1980’s, killing over 60,000 people due to hunger, malnutrition, open sewage, the cold, medical experiments gone wrong, severe punishments, and diseases, only coming to an end with the Psychiatric Reform in Brazil, which took place in the last decade of the twentieth century. With this in mind, we will tell the story of Luizinho, Corporal and Conceição  – three patients who were victimized by the Colony –, analysing, after, the bodies that exerted their powers over them inside Barbacena, from a Foucauldian standpoint. We will verify, next, how legislation and practices regarding the care and perception of people who are suffering psychologically changed over time and, finally, the state of psychiatric institutionalization in Brazil today. Keywords  Brazilian holocaust · Psychiatric institutionalization · Legislation and practices · Legislative history · Bodies and powers · Psychiatric reform

Excluded because misunderstood, excluded because dangerous, the mentally ill continue to be kept beyond the human limit, as an expression of our dehumanization and of our inability to understand (Franco Basaglia 2005, p. 44). A. P. Barbosa-Fohrmann (*) Department of Legal Theory, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil e-mail: [email protected]; http://lattes.cnpq.br/4012995260619181 A. C. P. Aubert Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Research Group on Human Rights Theory (NTDH) at the Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Research and Extension Group in Bio and Human Rights at the Federal University of Uberlandia, Uberlândia, MG, Brazil; http://lattes.cnpq.br/2005170752734528 © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_6

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6.1 Introduction In the book Holocausto Brasileiro (2019) – ‘Brazilian Holocaust’ –, Daniela Arbex narrates the tragedy that took place at the Hospital Colônia de Barbacena (henceforth referred to simply as ‘the Colony’ or ‘Barbacena’), which lasted between the 1930’s and the 1980’s, killing over sixty thousand people, only coming to an end with the Psychiatric Reform in Brazil. This book was then turned into a documentary (Mendz and Arbex 2016) and, for the first time, this purposely forgotten event was made public, though not with the attention it deserved. And even though the Psychiatric Reform was responsible for improving the way people who are suffering psychologically are treated, there is still a long way to go: discussing the past, analysing our legislative history and understanding the current situation are, therefore, of the utmost importance. With that in mind, we will tell, here, the stories of three subjects who were victimized by the Colony – Luizinho, Corporal and Conceição. Afterwards, we will adopt a Foucauldian standpoint to analyse the bodies that exerted their powers over them inside the walls of Barbacena. Next, we will verify how legislation and practices regarding the care and perception of people who are suffering psychologically changed over time, and, finally, we will look at the current state of psychiatric institutionalization in Brazil today. We hope to reveal, in the end, that even though we have come a long way, there is still a lot to be done in order to assure the dignified treatment of people who are suffering psychologically.

6.2 Brazilian Holocaust: Barbacena’s Genocide The deaths that took place in the Colony were due to many reasons, such as hunger, malnutrition, open sewage, the cold, medical experiments gone wrong, severe punishments, diseases, and so forth. It was, in short, a completely unwholesome environment (Arbex 2019). The dead bodies were then thrown into unidentified ditches or, worse, sold to important universities in Brazil to be experimented on all over again (Arbex 2019). Bodies violated in death as they had been in life in the name of the same rationality that those bodies presumably did not possess, stripping them of any control over their existences. The interns in Barbacena, because of overcrowding, did not sleep on beds, but on piles of grass filled with bugs. This allowed the Colony to fit the over five thousand patients into a space designed to accommodate no more than two hundred, but it also forced the patients to sleep one on top of the other, protecting themselves from the cold, and causing some of them to die during the night, deprived of oxygen. This is how Marlene, who worked as an attendant at Barbacena, depicted the horrifying scene inside the Colony:

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Next to the bush there were scrawny human beings. Two hundred and eighty men, most of them naked, crawled across the white floor with black ankles amidst the filth of the open sewer that crossed the entire pavilion. (...) she [Marlene] tried to avoid stepping on those disfigured beings, but there were so many that there was no way to avoid them. (...) she saw in a corner of the ward a corpse mixed with the living. She watched as two men in white coats wrapped the dead man in a sheet, the sixteenth body that day (...). In an attempt to keep warm during the night, patients slept in a pile, and it was common for those below to be found dead. (Arbex 2019, p. 18–20; own translation).

The patients in Barbacena were not only adults; there were also infants. After Oliveira Hospital  – that sheltered only women and children  – closed in 1976, Barbacena Hospital started to take those patients in, receiving children with all kinds of presumed physical and mental disabilities (most of them rejected by their families), and these toddlers were subjected to the same violence that subdued the adult inmates: they were experimented on, enslaved, physically and medically restrained, exposed to the cold temperatures during the night, and so forth (Arbex 2019). The patients of the Colony were not seen or treated as individuals or subjects, but as parts of a wider body: they were excluded and exterminated for what they represented as a group (heterogeneous as it may have been) of unwanted and abnormal people. They were undesired by a hygienist and eugenic society, but were nonetheless useful, even if just as guinea pigs, slaves, or symbols of what people should not aspire to be. In fact, the very decision as to which ‘patients’ to take in was based on eugenic principles of social cleanliness and, to that extent, served society, as it allowed it to get rid of those unwanted by it. This means that there were no objective criteria to set apart someone who was actually ill and in need of some sort of treatment, and someone who just did not fit into society’s normative framework, responsible for normalizing people’s traits and behaviours. In fact, most patients there had no mental illnesses whatsoever: they were people who came from families – mostly poor, black or both – who did not understand or want them, or were taken from the streets by the police when found wandering without occupation. Their bodies were thrown into the Colony and stripped of their identities. It was a lucrative business that served the purpose of cleaning the streets of those who ruined the scenery (Arbex 2019). The interns were taken to the Colony by train. The trains that led to Barbacena Hospital were described by Brazilian writer Guimarães Rosa1 as “trem de doido” (“cuckoo train”). After the ride in a cabin meant only for the crazy, they would descend at Bias Fortes’ station, which resembled, in many ways, Treblinka’s station: they both afforded a sense of normality to the stop, as if they were ordinary stations, regardless of the horrible fate that awaited the passengers (Arbex 2019). Let us recollect, here, Eichmann’s report that stated that Treblinka’s station was built with the sole purpose of receiving individuals to be dispatched and, regardless of that, it could be mistaken for any other train station in Germany, with “the same

 Guimarães Rosa describes the train that goes to Barbacena in the tale “Sorôco, sua mãe, sua filha”, in the book Primeiras Estórias (2019). 1

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buildings, signs, clocks, installations; it was a perfect imitation” (Arendt 2006, p. 118). We will tell here the story of three different victims of Barbacena, told by Arbex (2019) in her book. Three subjects who were considered to be sick because they were different, and locked away because they were abnormal.

6.2.1 Luizinho Luizinho was a black boy, enslaved long after slavery was supposed to have ended. In Barbacena, he was forced to build houses sold by one of the staff members of the Colony, who would hit him for no reason and pay him no money for his work. He would also freeze during the nights, since no one would provide him and the other patients with sheets or blankets. Luizinho’s story begins with his mother, Donana. Donana was an illiterate 34-year-old woman who, like her own mother, supported her family with the money she made as a laundress in the small town of Grão Mogol, located in the very arid and beautiful Serra do Espinhaço, in Minas Gerais, with its savannah vegetation and past diamond-mining tradition. When Donana gave her son away to be treated by the Oliveira Hospital, she had been a widow for two years, after her husband had choked to death, leaving her alone to take care of their son and daughter. It was the 1950’s when the shy 16-year-old boy started to reveal his illness: quiet, he wouldn’t play in the streets with other boys his age, isolating himself in the very simple mud house where they lived. Thankfully, Donana had heard important news of a medical treatment available for people like her son and, like any loving mother, she only wanted the best for him. If doctors were saying there was something wrong with him, and that his illness could go away, who was she to disagree? Even without a proper diagnosis – what was that, anyway? –, she became convinced that the boy was mentally ill and should therefore be institutionalized, at least for a while, in the neuropsychiatric hospital advertised for people in the region. On the day set by Oliveira Hospital to collect the children considered to be mentally ill from the towns in the region, Donana dressed Luizinho in his finest clothes: a white long-sleeved shirt with a frayed fabric, and patched pants that were his sole inheritance from his late father. She said her goodbyes reassuring her boy – and, why not, herself – that they would be reunited soon. Little did she know that that was the last time she would ever see or hear from him. On the day Luiz Pereira de Melo was brought to Oliveira Hospital, he became the property of the state. After Oliveira closed, he was sent, in 1952, to the Colony. Days became weeks, weeks became months, months became years and years piled up to a lifetime. After he was taken, Donana tried very hard to get in touch with him. Since she did not know how to write, she would ask her neighbours to help her with that task, and was then able to send letters to him. Still, Luizinho never got any of them, being

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left to believe that his mother, too, had forgotten all about him. Donana spent 32 years leaving her son’s bed made up for him, hoping he would enter through their house door at any moment. He never did, and so she died in 1976 without ever seeing him again. At the age of 84, Luizinho misses his childhood home and his mother’s loving touch.

6.2.2 Antônio Gomes da Silva Antônio Gomes da Silva or, as people preferred to call him, “Cabo” (“Corporal”), was 25 years old when he was sent to the Colony. Apparently, he was arrested for being an unemployed drunk unable to control himself and, at some point, a police chief decided to send him from prison to the Colony. He never knew why. And even without a crime, a trial or a sentence, he spent close to half a decade imprisoned. In the hospital, he says that although there were more than enough clothes in the laundry room, he had to remain naked, which bothered him at first, but eventually he grew accustomed to it. He remained silent for twenty-one years during his imprisonment, and everyone just assumed he was mute. One day, he simply broke out of his silence when he heard the police band playing. “Why didn’t you tell anyone that you could speak?” (Arbex 2019, p. 28; own translation), asked one of the staff members of the Colony; “Because no one ever asked!” (Arbex 2019, p.  28; own translation) A similar assumption was made regarding his ability to write: he spent years signing documents with his finger prints, even though he was perfectly able to write his own name. He describes the Colony as, literally, hell on earth. In 2003, he was finally freed from the Colony and sent to live in a therapeutic residence in Barbacena, maintained by a partnership between the city and an NGO. He was surprised to find that, for the first time, he was in control of the lights: no one would turn them on or off just because it was time to sleep or to wake up. His time was finally his own.

6.2.3 Conceição Machado Conceição Machado was sent to the Colony at the age of fifteen. The reason? She had decided to demand that her father paid her as much money as he did her brothers for their work at his farm. The farmer found her request to be an indication of rebelliousness and, as a punishment, sent her to the Colony in 1942. She never left and, for thirty years, never had any visitors. At first, she fought her diagnosis with all her strength: she was not crazy and no one could tell her otherwise. But after her botched attempt, she was locked away in a less than 10 square meter cell, allowed to see daylight for no longer than twenty

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minutes a day. She became, nonetheless, an active figure in the Colony, fighting for better conditions for herself and for the other interns. Like Luizinho and Corporal, and like the rest of the patients in the Colony, she too was victimized by electroshocks. According to Doctor Ronaldo Simões Coelho, who was hired as a psychiatrist by the State in 1971, the electroshocks “were given indiscriminately. Sometimes the city’s electrical power was not enough to handle the load. Many died, others suffered serious fractures” (Arbex 2019, p.  30; own translation). The experience of Francisca Moreira dos Reis, a kitchen employee that was trying for the position of nursing assistant, illustrates in great detail the violence of this type of ‘medical’ procedure: Francisca (…) and twenty other women were selected to perform an electroshock session on the male patients of the Afonso Pena pavilion, randomly picked (…). Her colleague, Maria do Carmo, who also worked in the kitchen, was the first to try (...). The heart of the victim failed. The patient died there and then, of cardiac arrest, in front of everyone (...). Immediately, the hospital attendants wrapped the poor thing in a sheet, as if it was not a corpse at all. They simply made the package, put it on the ground, and the still warm body waited for someone to take it to the morgue. ‘One down’, thought the guard while he carried out the task. (…) The second candidate approached the other bed and, trembling, began the test. (…) The patient chosen was even younger than the first. He seemed to be under twenty years old. (…) He did not resist. It was the second death of the night and classes were just starting. (Arbex 2019, p. 33–34; own translation).

Like Francisca, many of the employees of the Colony had no experience whatsoever with medical treatment or nursing in any way. They needed no education or experience to get the job. They were told to give a blue pill, a pink pill or both depending on the patient’s behaviour, and no other information was necessary or available (Arbex 2019).

6.3 A Foucauldian Analysis: Bodies and Powers in Barbacena Unwanted and feared, the interns in the Colony were excluded from their communities in order to be imprisoned in a space governed by a power that sought to control them fully: their bodies, their habits, and their thoughts. And this political technology called discipline was both omnipresent and omniscient, with a watchful eye that remained hidden, but ever-present, ready to examine and punish anyone who did not comply with social norms. Luizinho, Corporal and Conceição were forced to leave their identities and loved-ones behind for good, and to cut relations with anyone or anything from their

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old lives, becoming, then, a-historical.2 Their bodies were transformed into political entities (Foucault 2021) and became, furthermore, objects of the psychiatric domain that medicalized them, i.e., their personality traits became medical conditions3 and they were seen as sick and in need of treatment. In other words, these subjects were eventually turned into objects4 and their personalities became diseases5 (Caponi 2012). Discipline exerts a power, but it also produces a knowledge, and individuals such as Luizinho, Corporal and Conceição were products of both power and knowledge. It was the Colony, furthermore, the body which produced them not as crazy people, but as mentally ill, submitted, therefore, to the knowledge of psychiatry. They were individuals produced by disciplinary power, and subjected to the development of knowledge, which exerted a power over them (Machado 2021). Deemed to be irrational6 and incapable, Luizinho, Corporal and Conceição violated moral and normative frameworks, designed to normalize people’s traits and behaviours and, for that reason, they were to be stripped from the social scene completely. Being diagnosed as ‘alienated’, they became others, strangers, foreigners; people who could not tell right from wrong and, therefore, posed a risk to society’s

 Basaglia, about the internment, contends that “the absence of any project, the loss of a future, the permanent condition of depending on others, without any personal initiative whatsoever, with days divided up and ordered according to schedules dictated solely by organizational demands that – for this very reason  – cannot take into account the unique individual and their particular circumstances: that is the institutionalizing scheme by which life in asylums is articulated” (Basaglia 2005, p. 24–25; own translation). 3  Mental suffering cannot be located in a specific organ, or in a specific part of the body; it is a condition that takes hold of the subject in their totality; “a suffering we call confusingly ‘mental illness’ or ‘psychiatric disorder’” (Caponi 2012, p. 34; own translation). And because the disease cannot be seen in the body, leaving no clear marks to indicate that it is there, psychiatry is forced to establish proof mechanisms capable of demonstrating that there is an illness, even if it does not show in a way clinical medicine could perceive it. “It will be necessary to expose what is hiding, what is hidden, not in the interior of the body, tissues or organs, but in the behaviour, habits, action, family background, life history – a task to be accomplished by the utilization of one of the privileged techniques of intervention, which is the psychiatric interrogation. The psychiatric interrogation seeks to find, in reported past conducts, an indication of behaviours or abnormal reactions that show the silent existence of the disease” (Caponi 2012, p. 40; own translation). 4  Inside the walls of the asylum, Basaglia points out that the patient loses their individuality, being completely objectified. “If mental illness, in its origin, is the loss of individuality and of freedom, in the mental asylum the mentally ill will find nothing other than the space where they will see themselves definitely lost, transformed into objects by their illness and by the rhythm of the internment” (Basaglia 2005, p. 24; own translation). 5  Foucault states, in Os Anormais (Les Anormaux) (2010), that with the birth of psychiatry, no behaviour or conduct is free from being questioned and examined by this medical position. 6  Alienated people presumably did not possess the attribute of reason, which is a necessary condition to define human nature as it was developed in the Modern Age, differentiating human beings from other exploited non-human animals. For that reason, they were not regarded as citizens. Furthermore, without Reason, there was no free will and, hence, no true freedom. In order to become free, these individuals had to be treated and freed from their own imprisoning minds (Amarante 2007). 2

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order and safety7 (Amarante 2007; Foucault 2010). This is why they belonged in the hospital,8 where disciplinary power would examine them, registering and producing knowledge9 constantly (Machado 2021; Amarante 2007; Foucault 2019). Luizinho was shy. Corporal was an irresponsible drunk.10 Conceição challenged not only her father’s orders, but also the gender inequality that translated into her unjustly lower pay checks. And just like that, they were locked away for good, because in a society ruled by disciplinary power, which examines and controls, in detail, the body and its gestures, attitudes and behaviours (Machado 2021; Foucault 2010), only people deemed normal could be free (Amarante 2007; Foucault 2010), keeping society safe from their dangerous abnormalities, under watchful eyes. In that sense, mental asylums were no different from prisons11 (Foucault 1987, 2003). Luizinho, Corporal and Conceição were taken away from society, but they were not totally dispensable. In fact, not only were they used as forced labour (a repetitive ‘therapeutic’ labour that was not supposed to enslave them, but to eventually free12 them from their own disturbed minds, and that also revealed the importance of morality, manifested both through work and religion) and for medical experiments, but more importantly, they served as a reminder of what people should not aspire to be; of the very animality13 people should steer themselves away from, keeping their  Isolation served two purposes: (i) assuring a harmonic social order, protecting citizens against threats and disorder; and (ii) freeing alienated people from their own madness. In this second case, Philippe Pinel, known as the father of psychiatry, believed that moral treatment meant “creating strategies to dominate passions and regain reason, that is, to re-establish the lost normality in order to achieve freedom. It is in that disciplinary context that asylum incarceration finds, in Pinel, its justification (…)” (Caponi 2012, p. 51; own translation). 8  Hospitals, during the Middle Ages, used to be spaces for charitable work, religious assistance and shelter. With the French Revolution and Philippe Pinel’s creation of modern clinical medicine and of psychiatry in the form of Alienism, these spaces were subordinated to the ruling of the medical body (Amarante 2007; Foucault 2010). 9  According to Paulo Amarante, “the replacement of absolutist society (monarchical, totalitarian, and clerical) by the disciplinary society assigned a new role to institutions: the discipline of bodies, the introjection of the norms of the social pact built between peers, the normalization of citizens and the very notion of citizenship. This is how hospitals – that used to be a place of mortification and ‘de-historization’  – became a place of truth, knowledge, and positivity” (Amarante 2007, p. 26–27; own translation). 10  In Morel’s (1857) degeneration theory, drinking is an important cause of degeneration: alcohol affects individuals, families and peoples, hurting the nervous system, and producing, potentially, “the highest degree of degradation that a man can achieve” (Caponi 2012, p. 91; own translation), as it produces the complete abolition of every moral sentiment. 11  In Surveiller et Punir: Naissance de la prison (1987), Foucault’s interest turns to the “disciplinary power, normalization, how truth and power articulate, and the tactics to control time and space” (Caponi 2012, p. 33; own translation). 12  As stated by Franco Basaglia, “the freedom mentioned by Pinel had been conceived in a closed space, and left in the hands of the legislator and the doctor, who should dose it and maintain it” (Basaglia 2005, p. 23; own translation). 13  According to Basaglia, “when facing their fears and the need to take responsibility, men tend to objectify in others the part of themselves that they cannot control: that is, exclude from others the abject part of themselves” (Basaglia 2005, p. 37; own translation). 7

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thoughts and behaviours in check, within normative and moral frames responsible for their normalization, for the sake of the proper functioning of the industrial and capitalist society14 that required productivity to grow to its full potential (Machado 2021).

6.4 A History of Brazilian Legislation Regarding the Psychiatric Institutionalization of Those Considered to Be Abnormal In the 19th and 20th centuries, Brazil was subject to, as many other places were, hygiene policies brought on by the pseudoscience of eugenics and everything it entailed. Bénédict Morel’s15 vision of what he called ‘degenerates’ and his famous Traité des dégénérescences physiques, intellectuelles et morales de l’espèce humaine et les causes qui produisent ces variétés maladives (1857) arrived in Brazil via a program that aimed to fight miscegenation between Brazilians and to Aryanize the “Brazilian race” (Pereira 2008, p. 491), while Galton’s eugenic theory was brought to Brazil by Renato Kehl, a doctor who founded the Eugenic Society of São Paulo (Engel 2001). Abnormal individuals started, then, to be sterilized, and their marriages controlled, for there was a concern, at that time, that abnormal children would come

 “My hypothesis is that with capitalism there was not a change from a collective medicine to a private one, but quite the opposite; that capitalism, developed during the end of the eighteenth century and beginning of the nineteenth century, socialized a first object, that is, the body as productive force, as work force. Society’s control over individuals does not operate simply by consciousness or ideology, but begins in the body, with the body. Capitalist society invested, above all, in the biological, somatic, corporal dimensions. The body is a bio-political reality. Medicine is a bio-political strategy” (Foucault 2021, p. 144; own translation). 15  Morel’s degeneration theory was developed as an attempt to respond to the difficulties psychiatry was facing during the second half of the nineteenth century, when an increasing number of alienated people were being sent to asylums and the ‘moral treatment’ defended by both Pinel and Esquirol was proving insufficient to solve the problems of the abnormal and their multiplication. It is in this context that Morel tries to create a reliable and consistent classification of mental pathologies. Morel also works with the therapeutic strategy known as ‘moral treatment’, but not in the same way as Pinel or Esquirol. His method consists of “the application and propagation of a series of moral hygiene rules destined not only to the alienated, but also to populations in general. “That is what Morel (1857 quoted in Caponi 2012, p.  96, own translation) calls ‘moralization of the masses’. Such rules would be imposed by a moral law that was “divine, still, and immutable” (Caponi 2012, p. 96, own translation). 14

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from these marriages, growing up with tendencies to crime and sexual perversion16 (Lobo 2015; Foucault 2010). According to Brazilian historian Magali Engel (2001), what happened at the turn of the nineteenth century was that, with the spread of Morel’s theory in Brazil, madness started to be perceived as a disease, and so it became the object of intervention by physicians. What was new, then, was “giving madness a specificity by starting to conceive of it, above all, as a disease, seeking, thus, to transform it into an object of knowledge and intervention exclusive to the physician” (Engel 2001, p. 118; own translation). In this sense, the more the theory of degeneration spread, the more madness was perceived, in the discourse of specialists, as dissociated from delusion and as a form of mental alienation. From that moment on, psychiatrists were tasked to deal with this. The lunatic became, as pointed out by Foucault (2019), alienated, and the body of medicine started to rule over the personalities of each individual, normalizing and disciplining them. Before that, Engel (2001) states that if you were to go for a stroll on the streets of early nineteenth century Rio, you would surely find mad people wandering the streets as part of the bohemian scenery of the city. According to her, they were not necessarily feared and were, in fact, incorporated into the daily life of the city. These people would circulate freely on the streets, in control of their own bodies and of their own lives. What did already exist was the practice, by richer people, of isolating those family members who were considered insane, and who would then be kept apart from the social scene, left in places such as the Santa Casa da Misericórdia. Institutionalization was not, however, a systematic practice (Engel 2001). Things started to really change only later that century. Before that, there was no direct relation between health and the state apparatus (Martins 2020).17 During the colonial period, there was no real intent to fight the causes of diseases, and medicine was not as present in society as it later became, when medical practices were incorporated into the urban setting. At that time, Roberto Machado reveals that health did not appear as something that could be “produced, encouraged, organized, increased” (Machado et  al. 1978, p.  56; own translation), but only as a response to disease itself. Public hygiene became, then, a facet in social medicine, with its political and medical control mechanisms, that looked not only at the existing illnesses, but at their causes, rooted within disorganized and malfunctioning societies.  In Les Anormaux, Foucault (2010) emphasizes the importance of the inheritance of abnormalities and degenerations (Barbosa-Fohrmann 2021, p. 28–29; 2016, p. 744–748): “Abnormal people cannot be considered carriers of a disease in particular, but subjects who anticipate an unlimited and undefined number of potential illnesses in their offspring. […] This bio-political strategy does not aim to heal or normalize deviations; its main goal is to anticipate the birth of danger. With that purpose in mind, a medical-political instrument capable of controlling the progeny of the great degenerate family will be built, also aiming to control dangerous races and populations: the hygienist and eugenic strategies of the 19th and 20th centuries. The main target of these strategies was to control abnormal families” (Caponi 2012, p. 27; own translation). 17  See Barbosa-Fohrmann and Martins 2021. 16

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“Dangerousness is born, and with it, prevention” (Machado et al. 1978, p. 155; own translation). When the Portuguese royal family came to live in Rio de Janeiro, in 1808, an important process of change was put in motion, with new repressive policies and improvements in cultural establishments in the city. Also, habits considered to be primitive that prevailed inside poor or rich houses began to change as well, becoming more European. This involved not only customs, but also, more deeply, the creation of the very idea of privacy inside each home, individualizing each member, and putting an end to the constant cohabitation of masters and the enslaved. Doctors would also recommend that windows should be kept open to avoid closed spaces,18 boys should exercise, children should go to boarding schools to stay away from the vicissitudes of their homes, and the very perception of infancy would change. Outside family homes, the streets should also be kept clean and in order, a task Father Feijó, regent at the time, would take into his hands, creating a military force outside the army he called the Permanent Municipal Corps (Corpo Municipal dos Permanentes) (Lobo 2015). At the end of the nineteenth century, when Brazil became a republic free of slavery, Rio started to aspire to becoming something like a postcard, giving way to hygienist measures: wanderers, hobos or bums belonged in a grey area between legality and criminality, and should hence be locked up, alternating days of freedom and imprisonment in police stations, in the House of Detention and, increasingly, in the National Asylum, the Colonies of the Alienated and, from 1921 on, in the Judiciary Asylum (Engel 2001). The grotesque power described by Foucault was found more and more in the beautiful scene of Rio de Janeiro (Engel 2001). Alienated individuals should not be free to wander the streets: they should be institutionalized19 in mental asylums, and their bodies controlled. That was when medicine, as a knowledge and a power, started to invade every domain in society (Machado et al. 1978). Social medicine became part of the state machinery, and new public health policies started to appear (Martins 2020). “New disciplines to deal with the urban phenomenon [were developed]: social medicine, hygienist measures, sociology, psychology, statistics, new means of intervention” (Lobo 2015, p.  287). And with this shift, popular figures such as Seixas, who would always walk barefoot; Capitão Marmelada (“Captain Marmalade”); Mamãe (Mommy), perceived as stupid, filthy, and always smoking large cigars; and Tamandaré, the drunk (Costa 1957, p. 87), were no longer welcome.

 “Urban medicine has a new object: the control of circulation. Not individuals’ circulation, but of things and elements, essentially water and air” (Foucault 2021, p. 159; own translation). 19  Institutionalization relates “to the historical production of general forms that are the institutions, which, once built, produce and reproduce relations based on force (domination, struggle and resistance) (…). From that point of view, the process of institutionalization covers more or less discursive practices of separations, not only with the exclusion of the leprous or the imprisonment of the mad, for instance, but also with the validation that the knowledge promotes through classifications, specializations and their established truths” (Lobo 2015, p. 332; own translation, author’s italic). 18

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Engel (2001) describes something quite similar to what we saw in Arbex’s descriptions of the Colony: the different diagnosis of madness, although performed by trained psychiatrists, was based on the most diverse traits of character that had nothing medical about it, like shyness, sadness, or anything considered to be present in an excessive manner. People considered to be abnormal or unfit in any way would then be diagnosed as dangerous alienated people, who should face incarceration and ‘treatment’. Bodies and behaviour became objects of control and examination within the normalization framework: if people gave in to uncontrolled passions, the body would fade (Lobo 2015). Inside the asylums, physical therapies developed in Europe during the first half of the nineteenth century, such as insulin shock therapy or insulin coma, electroconvulsive therapy, lobotomies, and so forth (Martins 2020) were tested on patients in Brazil. And apart from experimenting on subjects, mental asylums were also spaces of repression, which was made clear by Decree no. 1077 of December fourth, 1852, that regulated Pedro II Mental Asylum and described, in article 32, the means of repression allowed to make alienated people comply with the rules, such as (i) deprivation of visitation or leisure of any sort; (ii) restriction in the quantity of food offered; (iii) solitary reclusion; (iv) physical restraint through the use of straitjackets; and (v) drowning baths, which were, of course, a form of torture. Amarante (2007) tells the horrifying story of a woman who was locked in a cell inside a mental asylum and forgotten there, only to be found already petrified years later, having died of hunger and cold. After her body was removed, its mark remained, and no cleaning product could erase it: they had to remove the floor. In 1934, a new constitution was enacted, and it specifically established that those who wanted to be married should prove their physical and mental sanity before they could officialize their bond. Eugenic education was also stimulated. A new constitution was enacted in 1937, but those ideals remained, with the inclusion of a provision that gave workers and pregnant women the right to eugenic assistance (Martins 2020). Decree no. 24,559 of 1934, signed by the then President of the Republic Getúlio Vargas is a good example of a law that looked not only at those already considered to be ‘psychopaths’, but also those predisposed to mental illnesses.20 During the Vargas era, the asylum apparatus of the state was consolidated as a hygienist instrument of exclusion and segregation of people in psychological distress, who were set apart from their political communities. Members from both medical and legal bodies would participate on the Council for the Protection of Psychopaths, which was supposed to study the social problems related to the protection of these individuals, as well as to analyse what measures should be taken by the government to benefit them. Also, the Council would help mental hygiene

 In such cases, it was possible to try to prevent future degenerations, even if through compulsory sterilization. 20

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propaganda agencies, legitimizing the social exclusion of these people in the name of building a national identity (Martins 2020). Cases of drug and alcohol abuse were also treated in psychiatric establishments; thus, drugs, alcohol, and mental illnesses were intimately related to one another and to the diagnosis of madness (Martins 2020). The people responsible for the internment of these abnormal subjects were judges, police authorities, spouses, parents, children or relatives up to the fourth degree, tutors and so forth, in the form of either involuntary hospitalization or of hospitalization at the request of third parties (Martins 2020). Later, in the 1940s, as a result of Decree-Law no. 3171 of April 24, 1941, the National Service for Mental Illnesses – an organ that belonged to the Ministry of Education and Health – was created to carry out a preventive psychiatric care policy. The policy also marked the 1970s, with the emergence of the National Mental Health Division, as a result of Decree no. 66,623 of 1970 (Martins 2020). During Juscelino Kubitschek’s presidency and throughout the military dictatorship that took place from 1964 on, urbanization and industrialization brought a new figure onto the scene: the private psychiatric hospital. Places like this would not only isolate the mentally ill, but also make a profit out of it (Martins 2020). During the 1970’s, however, the asylum model was facing a crisis internally and internationally, and so was social security, making room for the Sanitary Reform, the Anti-Asylum Movement and the Psychiatric Reform. But it was in the 1980’s that changes in the psychiatric care model really started to show: the first Psychosocial Care Centre in Brazil was opened in 1986 (called Professor Luiz da Rocha Cerqueira), in the city of São Paulo, followed by other important events, such as the I National Conference on Mental Health, in Rio de Janeiro (1987), the II Meeting of the Workers Movement on Mental Health, in São Paulo (1987), the intervention of the City of Santos in the Anchieta Health Home (1989) and the presentation of bill 3657. Finally, in 1988, a new constitution was enacted and many fundamental and social rights gained constitutional force in our legal system (Barbosa-Fohrmann and Martins 2021; Martins 2020). A case that became quite famous not only in Brazil, but also internationally, was that of Ximenes Lopes, a 30-year-old boy with a disability, institutionalized in Casa de Repouso Guararapes, in Sobral, Ceará, who was killed in October 1999. The case ended up being tried by the InterAmerican Court of Human Rights in 2006, and Brazil was convicted (Aubert 2021). According to the sentence, Damião Ximenes Lopes was admitted on October first 1999, to receive psychiatric treatment, and passed away a few days later on October 4th. He had already been admitted to Guararapes before, for a couple of months, and returned home with bruises on his knees and ankles, maintaining he had been treated violently there. Years later, when he was re-admitted, a few days after his admission he had an aggressivity and disorientation crisis, refusing to leave the bathroom, which led the nursing assistant with the aid of two other patients to forcibly remove him, injuring his face, and constraining him both physically and chemically.

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Later that day, Ximenes Lopes had another aggressivity episode and was then restrained physically until the next day. In the morning, his mother arrived at Guararapes and found him hurt, bleeding, with his clothes torn, a strong odor of excrement, and his hands tied behind his back. He also experienced difficulty breathing and was screaming to the police for help (IACHR21 2006). At night, he was medicated again, although he did not undergo any physical examinations and, after Guararapes’ clinical director left the establishment, leaving the institution without any doctors to attend to the patients, he passed away in violent circumstances, and completely unassisted (IACHR 2006). This case was definitely a victory for the movement against mental asylums, and it was tried at a time Brazil was facing important changes in its legislation regarding mental illness. In 2001, a very important law – law no. 10,216 – brought into effect, nationally, the event known as the Psychiatric Reform. This reform had started to take shape during the last decades of the twentieth century and fit into what was established by 1988’s Republic Constitution of Brazil, which protected the rights of people with all sorts of disabilities. Brazil was witnessing, during that period, a shift in its public policies regarding a new model of mental health care that was based not on segregation and hospitalization, but on social and family reintegration, with a change from the asylum model to the outpatient one. Still, after 12 years of law-making, the approved legislation text was not the same as the initial one, missing fundamental aspects such as the need for the progressive extinction of mental asylums. On the other hand, eight state laws were also passed during that period, contributing to the Psychiatric Reform, as well as many municipal laws (Amarante 2007). After the Reform, family and social community became important public health instruments in the recovery of those in psychological distress, and so, Centres for Psychosocial Attention were created (or, in Portuguese, Centros de Atenção Psicossocial - CAPS) (Barbosa-Fohrmann and Martins 2021, p. 9) and regulated by the Health Ministry’s ordinance no. 336/02, as part of the Unified Health System (SUS), that is responsible for providing universal, public access to nationwide health care. Their purpose was to receive patients with mental disorders, encouraging their integration in society and family, and supporting them in their search for an autonomous life. (Barbosa-Fohrmann and Martins 2021, p. 10). The final goal was to provide care for people who suffered from mental disorders, psychoses, severe neuroses and other conditions (including, here, addictions to drugs or alcohol), without practices of isolation or segregation, seeking to integrate these individuals into their communities, cities, and daily life, as full citizens with access to jobs, culture, leisure, and so on (Barbosa-Fohrmann and Martins 2021, p. 9). From that point on, these Centres assumed a strategic role in the organization of the community care network, guiding mental health policies and programs locally, by developing therapeutic and community projects, distributing medicines,

21

 Inter-American Commission on Human Rights.

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accompanying users who live in therapeutic residences, and so forth (Ministério da Saúde et al. 2004).

6.5 Psychiatric Institutionalization in Brazil Today Firstly, it is important to mention that we have seen some progress in some areas regarding overcoming the asylum model. A good example is the city of Sorocaba, located in the state of São Paulo, that used to have, until 2018, one of the highest concentrations of interns associated to the Unified Health System in Brazil (Garcia 2008), “known nationally as the largest asylum park in the country  – there were more than 2,500 spaces (not beds) of internment” (Surjus 2008, p. 57). After 2018, it was finally closed, because of an agreement between the Federal Public Ministry, the Federal Government (through its representative in the Ministry of Health and the Legal Consultancy with the Ministry of Health), the State of São Paulo (through its Health Department), the Municipalities of Sorocaba, Salto de Pirapora and Piedade, and seven private long-stay psychiatric hospitals in the region of Sorocaba (CFP et al. 2018). In the resulting document, the hospitals “undertook to transfer all their patients to the Psychosocial Care Network (RAPS) managed by the government” within three years. Furthermore, the agreement established “the creation of therapeutic residences and the granting of assistance benefits by the National Institute of Social Security (INSS) to interns” (CFP et al. 2018, p. 45 own translation). It is worth mentioning, nonetheless, that the situation in the country is far from satisfactory, which we can see clearly when we analyse the different reports on the situation of those people still locked up in mental hospitals. Arbex (2019) tells of a national inspection that took place in 2004 and that verified subhuman conditions in 28 different mental asylums. More recently, in 2017, the report intitled ‘Relatório da Inspeção Nacional em Comunidades Terapêuticas’ (CFP 2018) – or, in English, ‘Report on the National Inspection of Therapeutic Communities’, that investigated 28 therapeutic communities  – and another one called ‘Hospitais psiquiátricos no Brasil: Relatório de Inspeção Nacional’ (CFP 2020) – or, in English, ‘Psiquiatric Hospitals in Brazil: Report on the National Inspection’, that investigated 40 psychiatric hospitals throughout the country – identified, in many different units, practices of cruel punishments that included the enforcement of repetitive tasks, forced labour therapy in conditions similar to slavery (one case reported indicated that an intern was forced to help in the building of the owner of the establishment’s beach house for free), deprivation of meals, physical violence, long periods of isolation, sleep deprivation, random use of mechanical restraint or chemical restraint (drugs), disrespect for religious freedom (e.g., with the imposition of a rigid routine of prayers and punishment of those who refuse to participate), disregard for sexual orientation and gender identity, the presence of adolescents living with adults, children hospitalized by

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court decision (even though the Ministry of Health determines that therapeutic communities can only accommodate adults), in clear violation of Brazilian legislation. Brazilian anthropologist Debora Diniz wrote, in 2011, a census called Custody and Psychiatric Treatment in Brazil (2013), that aimed to verify who were the vulnerable and invisible people imprisoned inside judicial mental hospitals in the country, since there was very little official information on them. Diniz visited all of the 26 different facilities in the Federal District and other 19 states, and went through all of the 3989 files on interns. And even before she published her report, she directed a documentary in 2009 called “A Casa dos Mortos” (“The House of the Dead”), that was shot in the custody hospital of Salvador, Bahia, anticipating some information published later in her report. In the film, poet and intern Bubu narrates the stories of Jaime, who killed himself, Antônio, who was in and out of institutions, and Almerindo, whose identity and family relationships all died after years of imprisonment that greatly surpassed his two-year sentence (Diniz 2009). The places visited by Diniz for the census were not just mental asylums, but places meant for people who had committed crimes, but were not considered competent at the time of their actions and, hence, responsible, receiving not a penalty, but forced ‘treatment’, and people who lost their competency while answering for their crimes. The population who lived in these places was, before this report, unseen and unknown. And the report focuses precisely on those individuals that are under the dominance of those hybrid medical-legal knowledges described by Foucault, as we saw with Barbacena, the keywords being “peril” and “normality” (Diniz and Brito 2016). The analysis, which focused on profiling such individuals, was based on (i) socio-demographic data related to gender, age, race, education and profession (here, she concluded that most interns had not graduated from middle school – only 6% had graduated from high school and less than 1% had gone to university – and had professions that did not demand a formal education); (ii) legal itinerary data (e.g., criminal offence, reason for hospitalization, discharges and relapses, etc.); and (iii) mental health data (such as psychiatric diagnoses, risk cessation exams, deadlines and so forth). Regarding this last topic, Diniz informs that she regrouped the disability diagnoses into eight categories according to the ICD-10: epilepsy, schizophrenia, mental retardation, uni or bipolar disorders, personality disorders, sexual preference disorders, mental disorders due to the use of alcohol and other drugs and organic mental disorders (Diniz 2013). The first eerie conclusion is that the establishments described by Diniz do not date, necessarily, from before the Psychiatric Reform in Brazil: 25% of those psychiatric hospitals were built after (Diniz and Brito 2016), ignoring the change of policies on the care of people with mental disabilities from the asylum to the outpatient model. And just like we saw with Barbacena, the population imprisoned in mental hospitals is mostly made up of black, poor, and uneducated men. Poverty translated into social danger (Lobo 2015), because although inheriting abnormal traits was the main cause for becoming a degenerate, the external world was also a

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factor,22 hence the connection between the concern with degeneracy and spaces in which poor23 people live (Caponi 2012). Another concern relates to the fact that although people are not to be kept away in mental hospitals for longer than the maximum penalty prescribed for crimes, they are often left in those places for good. Also, one in every four interns were supposed to be free, either because of a sentence, a declaration that they were no longer a danger to society, the extinction of their penalties, etc., but remain unduly kept away. Not only that, 41% of the exams to evaluate if the peril of the interns has ceased or if it remains are late, and so the percentage of people irregularly institutionalized might be even higher. Furthermore, 47% of the imprisonments are neither based on legal nor on medical criteria. This model, as we see, is not that different from those hybrid institutions that we saw in the nineteenth century, subdued to police/judicial power, and run by biomedical knowledges (Diniz 2013). Diniz’s conclusion after what she declared to be unneutral research is quite relevant: “there is no inherent danger to psychiatric diagnoses” (Diniz 2013, p.  15; own translation). People in mental suffering are not more dangerous than other people considered typical, or at least there is no verifiable indication of that.

 As pointed out by Foucault, “Urban medicine is not truly a medicine of men, bodies and organisms, but of things: air, water, decomposition, ferments; a medicine of living conditions and existence’s environment. This medicine of things outlines, not yet employing the word, the notion naturalists at the end of the eighteenth century, such as Cuvier, will develop. (…) Medicine went from analysing the environment to analysing its effects on the organism and finally to analysing the very organism. (…) A great part of nineteenth-century medicine originated in the urban medical experience that was developed at the end of the eighteenth century” (Foucault 2021, p. 162–164; own translation). 23  According to Foucault (2021), during the eighteenth century, poor people were valued for the important activities they carried out in city life, such as delivering mail, collecting the garbage, and so forth. Poverty only became an issue for urban medicine during the second third of the nineteenth century, as a result of (i) the French Revolution, which made poor people feared for being a political force capable of revolting; (ii) the fact that in the nineteenth century it was possible to give up part of the activities performed by poor people by the establishment of mechanisms such as a postal system, for instance; (iii) the cholera outbreak in 1832 made people fear the poor and working classes as sanitary and political hazards. One of the causes indicated by Morel of degeneration is the social environment where the person lives. He describes, then, “a group of complex circumstances that tend to modify negatively poor people, making reference to the association, that marked the nineteenth century, between poverty and dangerousness” (Caponi 2012, p. 86; own translation). In Morel’s words, “if we observe the demoralizing influence of misery, lack of instruction, alcohol abuse, excess of diseases and malnutrition, we will have an idea of the complex circumstances that tend to modify negatively the nature of poor people” (Morel 1857, p. 56; own translation). Later, Valentin Magnan would also work with alcoholism as a condition related to degeneration, receiving awards from the Medical Academy and the Science Academy in 1872 for his work (Caponi 2012; see Magnan 1893). 22

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6.6 Final Considerations Barbacena was a tragic episode in our history that, unfortunately, indicates a tradition of excluding, eliminating and exploiting people who are psychologically suffering that do not fit into society’s normative and moral frames, responsible for the normalisation of its members. What was Luizinho’s crime? Being poor, black, and shy. Conceição’s offense, on the other hand, was standing up to the unjust treatment she received for being a woman, and Corporal drank and did not comply with social norms. The patients in Barbacena were no more than abnormal repulsive bodies, albeit good for forced labour and for experimenting on. Bodies that served as a reminder of what humans should not be, of the animality we should not give in to. The Psychiatric Reform that took place in the last decade of the twentieth century was responsible for important changes in the way mental health is perceived and dealt with, but, as we saw with the recent reports on the situation of people who still live in psychiatric hospitals – either inside asylums, therapeutic communities, or judicial asylums –, there is still a long way to go regarding the way we perceive mental illness, and the treatment we offer people who are suffering psychologically. Besides changes in legislation, it is necessary that, as a society, we reflect on social norms, (ab)normality, and why we feel the need to treat our own animality as an abject part of our humanity. Furthermore, we need to turn our focuses to the subjects suffering psychologically and not to their diseases, breaking away from prejudices towards what we consider to be irrational, immoral, dangerous and abnormal traits and behaviours. Finally, we desperately need to produce spaces for the care of subjects suffering psychologically, with reciprocity, intersubjectivity and their complete integration in the community as full citizens.

References Amarante, Paulo. 2007. Saúde mental e atenção psicossocial. Rio de Janeiro: Fiocruz. Arbex, Daniela. 2019. Holocausto brasileiro. Rio de Janeiro: Intrínseca. Arendt, Hannah. 2006. Eichmann in Jerusalem. Penguin Classics: A report on the Banality of Evil. London. Aubert, Anna Caramuru Pessoa. 2021. A história da deficiência, a internação psiquiátrica e a atuação do Ministério Público em alguns casos paradigmáticos. Escola Superior do Ministério Público do Ceará 13 (1): 245–267. Barbosa-Fohrmann, Ana Paula. 2016. Os modelos médico e social da deficiência a partir dos significados de segregação e inclusão nos discursos de Michel Foucault e Martha Nussbaum. Revista Estudos Institucionais 2: 736–755. https://doi.org/10.21783/rei.v2i2.76. ———. 2021. Do modelo médico ao modelo intermediário: uma reflexão teórico-prática sobre a inclusão de pessoas com deficiência. In Cruzando fronteiras: Perspectivas transnacionais e interdisciplinares dos estudos de deficiência, ed. Ana Paula Barbosa-Fohrmann and Inmaculada Vivas-Tesón, 23–43. Porto Alegre: Editora Fi.

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Barbosa-Fohrmann, Ana Paula, and Laércio Melo Martins. 2021. Previsão constitucional do direito social à saúde mental: novos caminhos para a reforma psiquiátrica brasileira. Pensar 26 (1): 1–13. https://doi.org/10.5020/2317-­2150.2021.10722. Basaglia, Franco. 2005. Escritos selecionados em saúde mental e reforma psiquiátrica. Rio de Janeiro: Garamond. Caponi, Sandra. 2012. Loucos e degenerados: uma genealogia da psiquiatria ampliada. Rio de Janeiro: Editora Fiocruz. Conselho Federal de Psicologia (CFP), et  al. 2018. Relatório da Inspeção Nacional em Comunidades Terapêuticas ─ 2017. Brasília: CFP. https://site.cfp.org.br/wp-­content/ uploads/2018/06/Relat%C3%B3rio-­d a-­I nspe%C3%A7%C3%A3o-­N acional-­e m-­ Comunidades-­Terap%C3%AAuticas.pdf. Accessed 7 June 2022. Conselho Federal de Psicologia (CFP) et  al. 2020. Hospitais psiquiátricos no Brasil: Relatório de Inspeção Nacional. Edited by Conselho Federal de Psicologia (CFP) et al. https://site.cfp. org.br/wp-­content/uploads/2019/12/Relatorio_Inspecao_HospPsiq.pdf. Accessed 7 June 2022. Costa, Luis Edmundo da. 1957. O Rio de Janeiro do meu Tempo, Vol. 5. 2nd ed. Rio de Janeiro: Conquista. da Saúde, Ministério, et  al. 2004. Saúde mental no SUS: os centros de atenção psicossocial. Brasília: Ministério da Saúde. http://www.ccs.saude.gov.br/saude_mental/pdf/sm_sus.pdf. Accessed 7 June 2022. Diniz, Debora. 2009. A Casa dos Mortos. Imagens Livres: Documentary directed by Debora Diniz. ———. 2013. A custódia e o tratamento psiquiátrico no Brasil: Censo 2011. Brasília: Letras Livres, Editora UNB. Diniz, Debora, and Luciana Brito. 2016. “Eu não sou presa de juízo, não”: Zefinha, a louca perigosa mais antiga do Brasil. História, Ciências, Saúde. 23: 113–130. https://doi.org/10.1590/ S0104-­59702016000100008. Engel, Magali Gouveia. 2001. Os delírios da razão: médicos, loucos e hospícios (Rio de Janeiro, 1830–1930). Rio de Janeiro: Editora Fiocruz. Foucault, Michel. 1987. Vigiar e punir: nascimento da prisão. Vozes: Trans. Raquel Ramalhete. Petrópolis. ———. 2003. Le Pouvoir Psiquiatrique. Paris: Gallimard. ———. 2010. Os Anormais: curso no Collège de France (1974–1975). WMF Martins Fontes: Trans. Eduardo Brandão. São Paulo. ———. 2019. História da Loucura. Perspectiva: Trans. José Teixeira Coelho Neto. São Paulo. ———. 2021. Microfísica do poder, ed. Roberto Machado. Trans. Roberto Machado. Rio de Janeiro: Paz&Terra. Garcia, Marcos Roberto Vieira. 2008. Alexandre, Presente! Sobre a banalidade do mal nos manicômios de Sorocaba. In Crônicas da resistência: fechamos o Vera Cruz, ed. Luciana Togni de Lima e Silva Surjus and Soraya Diniz Rosa, 61–67. São Paulo: Universidade Federal de São Paulo. Inter-American Court of Human Rights (IACHR). 2006. Ximenes Lopes v. Brazil. https://www. corteidh.or.cr/docs/casos/articulos/seriec_149_por.pdf. Accessed 7 June 2022. Lobo, Lilia Ferreira. 2015. Os infames da história: pobres, escravos e deficientes no Brasil. Rio de Janeiro: Lamparina. Machado, Roberto. 2021. Introdução: por uma genealogia do poder. In Microfísica do Poder, Michel Foucault, ed. Roberto Machado, 7-34. Trans. Roberto Machado. Rio de Janeiro: Paz&Terra. Machado, Roberto, et al. 1978. Danação da Norma: Medicina Social e constituição da psiquiatria no Brasil. Rio de Janeiro: Edições Graal. Magnan, Valentin. 1893. Recherches sur les centres nerveux. Alcoolisme, folie des héréditaires dégénérés. Paris: Masson. Martins, Laércio Melo. 2020. Saúde Mental: paradigmas e reformas legislativas. Porto Alegre: Editora Fi.

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Mendz, Armando, and Daniela Arbex. 2016. Holocausto Brasileiro. MAX: Documentary directed by Armando Mendz and Daniela Arbex. Morel, Benedict August. 1857. Traité des dégénérescences physiques, intellectuelles et morales de l’espèce humaine et les causes qui produisent ces variétés maladives. Paris: Baillière. Pereira, Mário Eduardo Costa. 2008. Morel e a questão da degenerescência. Rev. Latinoam. Psicopat. Fund. 11 (3): 490–496. https://doi.org/10.1590/S1415-­47142008000300012. Rosa, João Guimarães. 2019. Primeiras Estórias. São Paulo: Global. Surjus, Luciana Togni de Lima e Silva. 2008. Do lado de fora do muro: sobre o fechamento do maior hospício do Brasil. In Crônicas da resistência: fechamos o Vera Cruz, ed. Luciana Togni de Lima e Silva Surjus and Soraya Diniz Rosa, 56–61. São Paulo: Universidade Federal de São Paulo.

Chapter 7

Nootropics in the Era of Affective Capitalism: Drug Consumption and Discourse Effects Fabíola Stolf Brzozowski and Marcia da Silva Mazon

Abstract  This chapter discusses the transmutation of meaning from psychotropic to nootropic (drugs for cognitive enhancement) as a constituent element of the era of affective capitalism; a moment in which the public sphere is filled with problems of the private space. This change occurs at the moment in which the pharmaceutical industry gains muscles and actively participates in the training space of psychiatric professionals; one of the characteristics of the process that Lakoff names as pharmaceutical reason. To illustrate aspects of this new moment we bring data from interviews with undergraduate and graduate students who consume psychotropic drugs in the expectation of cognitive improvement. Although it seems unethical to medicalize people who are not sick, when these drugs are elevated to the condition of nootropics, the reasoning is inverted: it seems desirable and ethical to give citizens the opportunity for cognitive improvement, as a way to guarantee competitiveness in the neoliberal society. As important as talking about the effects of the increased use of psychotropic drugs in today’s society is to observe the effects of the discourses that put these drugs in circulation in the market under the nootropic label. Keywords  Markets · Pharmaceutical industry · Psychotropic consumption · Affective capitalism · Cognitive enhancement

7.1 Introduction In this chapter, we are interested in understanding the increase in the consumption of psychotropic drugs as a result of recent changes in society. According to Illouz, we live in the era of affective capitalism: transformations of contemporary culture and F. S. Brzozowski Municipality of Florianópolis, Florianópolis, SC, Brazil M. da Silva Mazon (*) Federal University of Santa Catarina, Florianópolis, SC, Brazil © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_7

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customs that have entered into a reinforcing relationship with therapeutic theories. These therapeutic theories are less an explanation of who we are and more means to convince us that we are; they exert an important theory effect (Illouz 2011; Cabanas and Illouz 2019; Illouz 2019). Thinking about societies in terms of the self – a consequence of this affective capitalism – leads to a particular change with regard to the way we manage our emotions and behaviours (Cabanas and Illouz 2019). But not only that. We argue in this chapter that this topic also dabs the question of how medications are legitimized as an alternative to alter, maintain, and enhance expected behaviours and emotions (Lakoff 2006; Rose 2013a; b; Illouz 2011). Cognitive enhancement or upgrading1 is an expression that is widely mobilized and legitimized at the present time and shifts the meaning of psychotropics to nootropics. According to Coveney et al. (2011) the appeal of drug use for cognitive improvement opens a new field of justifications for the use of psychotropic drugs by healthy people. This use would be beyond medical prescriptions. This is not a new topic, but it has gained new momentum in recent decades. Warm debates take place both inside and outside the academy, ranging from social media to legislative houses. This dichotomy of prescription drug versus cognitive enhancement is presented through drugs that were developed to treat diseases and disorders and are now being advertised by demands outside the medical authority. In these demands arises the desire that behaviour can be pharmacologically controlled for better performance and efficiency (Coveney et al. 2011). When we talk about our behaviours and emotions, this subject increasingly brings us to the topic of mental health; not that these themes were naturally connected, but this approach was built based on changes in society in recent decades (Corbanezi 2021). To understand the present moment, it is necessary to consider the post-war changes concerning the expansion and diffusion of the concept of mental health and the emergence of what Lakoff (2005, 2006) names as a pharmaceutical reason. According to Lakoff (2005), there is a strong relationship of interdependence between science, regulation, and the market in the circulation of pharmaceutical products. This relationship is best viewed not as contamination of pure science, but as part of an emerging regulatory framework of authoritative knowledge and expert action. For Corbanezi (2021, p.  19) the concept of mental health was patterned and expanded from the second half of the twentieth century as a result of a broad process of deinstitutionalization of mental illness in different Western countries, as well as the institutionalization of human rights, the development of psychopharmacology and the incorporation of the mental element in the health concept of the World Health Organization (WHO). The purpose of this great movement is to replace the hospital-centred model, humanize and prioritize investments in primary health care. According to Corbanezi (2021), and in line with the findings of Eva Illouz (2011), from the 1970s onwards there has been an intensification of processes towards the  Cognitive enhancement can be defined as the use of medication and/or other means with the aim of improving the cognitive functions of healthy subjects, especially memory, attention, creativity and intelligence in the absence of any medical indication (Brzozowski and Daré 2021, p. 205). 1

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neo-liberalization of Western societies, where the mental health discourse suggests a different meaning from what was intended in the field of the Welfare State and where certain diagnoses such as depression are trivialized (Corbanezi 2021, p. 20). The concept of medicalization – a process by which medical knowledge reaches not only everyday life and behaviours but also the very field of meaning of concepts and knowledge – has gained new contours in recent decades from the concept of pharmaceuticalization, which points to the leading role of the pharmaceutical industry (Conrad 2007, 2013; Coveney et al. 2011). Advancing the concept, Rose (2019) points out how psychiatric knowledge has dominated the contemporary scene constituting subjects and discourses. This new moment of medicalization points to a set of changes involving the decline in the role of physicians (Ravelli 2015; Mazon 2020, 2021) associated with the pharmaceutical industry’s leading role in these relationships (Conrad and Leiter 2004; Moynihan et  al. 2002). The pharmaceutical industry has even encouraged citizens to act as informed consumers by asking doctors for a particular drug (Rose 2013a). Social media and YouTubers encourage consumers to access medicines without the need to visit a doctor. These phenomena show how medicalization via the application of medical solutions to everyday problems can occur without the involvement and endorsement of physicians (Coveney et al. 2011). Although many studies focus, on the one hand, on the economic power of the pharmaceutical industry (Whitaker 2017; Frances 2016) and, on the other hand, on the charismatic and prescribing power of psychiatrists and psychiatry (Petryna et al. 2006), we propose looking at the phenomenon by investigating the context in which these drugs are mobilized and in which they become reasonable (Bourdieu 2006; Caponi 2019; Mazon 2019, 2020, 2021) appealing to Illouz’s concept of affective capitalism (2011, 2019). When Bourdieu discusses the real estate market, he mentions the effect provoked by advertising as poetic effects: advertising pieces bring up in people’s minds images of the seduction of advertising as a capture box that attracts them (Bourdieu 2006). When Bourdieu writes this work, on the one hand, there are home development and construction companies along with advertising and marketing companies, and, on the other hand, there are consumers, future buyers of these houses. When we talk about the discourse directed to psychotropics and their consumers at the current moment, these borders are more blurred. In the work of Bourdieu (2006), if advertising discourses try to frame people’s desires and dream of a home of their own associated with the idea of family, future, long term, and inheritance, in the current moment the discourses on psychotropic drugs try to fit dreams and expectations of an improved and enhanced self in broader rhetoric of control (Portugal and Vaz 2012). Associated with the idea of personal or neosubject efficiency as proposed by Dardot and Laval (2016) and in the justification of the correct strategy to obtain it; building a morally acceptable way of achieving this efficiency (Zelizer 2011, 1978a; Fourcade and Healy 2017). More than tacit knowledge, this environment can be thought of as creating knowledge with generative capacity – involving a moral and cognitive hierarchy of actors and processes (Lakoff 2006; Petryna et al. 2006).

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It is important to consider that since the 1990s in Brazil and from the liberalizing reforms, there has been an early movement of the deindustrialization of the national economy, which became generalized accompanied by the emergence of a new service providers class. There is an expansion of the tertiary sector within the scope of small businesses. Currently, almost 80% of existing jobs belong to the tertiary sector of the economy. There is a new booming service providers class. Part of it is linked to Information and Communication Technologies (ICTs) and exposed to uberism in organization and remuneration (Pochmann 2020). In the labour sphere, as well as in the twenty-first century student environment, these new performance needs/demands cannot be dissociated from the modern social instrumentality of drug use for non-medical purposes. It is important to consider that both work and student environments constitute “structured and structuring” spaces (Bourdieu 2009), which can generate effects in the reproduction of cultural dispositions for such performative consumptions. The non-medical use of drugs has become a means of achieving a certain image or socially expected performance standards; going further, the way each human being expresses himself within the framework of neoliberalism involves what Nikolas Rose calls a “neurochemical self” (Rose 1996, 2006, 2013b). This analytical perspective on the labour sphere is still timid (Carvalho et al. 2014). Considering the current phase of neoliberalism, which imposes new challenges to the standards of work performance, the work and training contexts constitute spaces with particular social permeability for the advancement, in the most diverse ways, of the pharmacologization of the ability to work and its valorization. We argue in this chapter that knowing the effects of discourses that put psychotropic drugs in circulation is a good clue to help understand the increase in the consumption of these drugs. That said, the objective of the chapter is a reflection on manifestations of pharmacologization and the ways of constructing meanings of psychotropics. Reflect on medicating yourself through the key of market exchanges in the era of homosentimentalis (Illouz 2011) bringing the lines of the interviews carried out in the Psychic Suffering Project Among University Students at the Federal University of Santa Catarina (Caponi et al. 2021).

7.2 Pharmacologization and Techonologies of the Self Foucault identifies as technologies of the self the different ways in which individuals convert themselves into support of their transformation. Throughout history, these technologies have helped them to reach a variety of states: renunciation of sexual pleasure or the practice of Christian confession are examples of techniques employed to achieve forms of purity. The twenty-first century seems to see the formation of a new kind of contemporary pharmaceutical self-help based on two bases: the first one that maximum performance is needed at work or in studies (either to help oneself or to help others), and the second that the best way to achieve this state is through cognitive-enhancing drugs, the so-called nootropics. This new condition

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consists of being awake longer or being more alert for different activities. These people believe that they will only be able to achieve their best performance from the moment they have ingested certain medications. Governmentality, as proposed by Foucault (Rose 2006, 2013a) is the set of dispersed concerns related to rationality and techniques implemented in the activity of governing. It is important to highlight that governing is not limited to the State here, but also concerns far-reaching initiatives as well as more mundane efforts aimed at directing people’s conduct, what Foucault called the art of government (Fridman 2019, p. 9, free translation). We can extend this reasoning to think of how individuals relate to their bodies as something to be enhanced and upgraded. In this key of analysis, the risk is reversed: there is no risk in self-medicating, there is a risk in failing to enhance, upgrading one’s cognition.

7.2.1 The Emergence of Pharmacologization The existing literature on pharmacologization tends to emphasize the gradual boundaries of drug use in new contexts where drugs were not previously employed, as well as the institutional dynamics and pressures that mold these boundaries (Whilliams et al. 2011). A smaller body of work has analysed pharmacologization and its social dynamics at a more micro level, exploring drug use in ways that denote not only the increasing “breadth” of drug use but also changing depth and texture (meanings and emotions) of medication use over time. This last approach highlights that pharmacologization involves the gradual sedimentation of knowledge, representations, and assumptions about drug types and their accommodation of meanings to solve particular “problems” in particular contexts (idem). Coveney et al. (2011) observe pharmaceuticalization in the context of labour transformation in the face of the new scenario of the digital era of the twenty-first century. This digitalization promotes new performance requirements in several sectors while blurring the boundaries between the private and public spaces of work. Although these drugs require a medical prescription, as is the case with Ritalin® (methylphenidate), the public perception of the drug’s result is based on a social imagination of its possible effects on the body. This imagination mixes the biomedical discourse, the media discourse and, as argued in this chapter, legitimizes itself in the era of affective capitalism. In the context of pharmaceuticalization and the world of work, pharmacological cognitive enhancers, PCDE (pharmaceutical cognitive enhancing drug), nootropics, or smart drugs can be highlighted. These products are medicines that aim to improve performance in intellectual production or productivity, whether in studies or at work. In other words, these are pharmacological interventions used to improve mental functions beyond medical indications (Schermer et al. 2009). Some examples of drugs used for this are modafinil (Stavigile® and Vigil®), amphetamines and derivatives, methylphenidate (Ritalin® and Concerta®), and piracetam. The literature describes some reasons why individuals use pharmacological enhancers: the need not to sleep and study, to increase concentration and alertness,

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and the pleasure generated by some of them (Teter et al. 2006; Gloria-Garcés and Vedana 2013; Morgan et al. 2017). It is possible to observe that the usage objectives are related to productivity, whether in studies or at work. Thus, the consumption of PCED appears to be related in the literature to this high pressure in work environments, one of the expressions of pharmaceuticalization (Coveney et al. 2011; Whilliams et al. 2011). The spread of pharmaceuticalization appears to be related to PCED. In the findings by Coveney et al. (2011), the authors found, in hospitals and clinics, an increase in the versatility required for these professionals (nurses), as well as, using digital tools, new forms of relationship with the public. In this context, some changes in the work environment can be mentioned: intensification of the workload and extravasation between the professional environment and the personal environment; professionals who deal with different situations (drug addicts, psychotics, among others); they have to deal with several tasks at the same time (filling out forms, seeing patients, answering the medical calls). In the authors’ findings, the uses of nootropics can be mobilized in different contexts: to increase performance, if there is a concern with the competition; for maintaining patterned performance (staying awake while working); and to improve the performance that already exists in terms of creativity. The authors conclude that performance improvement varies according to contexts and individuals (journalists, nurses, police officers). They are not morally equivalent practices: for some, performance improvement is self-serving (competition at work), an expression of related instrumental rationality. For others, performance is to better serve society (being able to serve more people and better, for example, nurses), better understood as a rational action in value, according to Weber (2004). In this sense, it is essential to observe the cultural representations of medicines, interactions in social networks, and daily performances which interact to shape different norms and expectations of drug use.

7.3 Diagnostics in the Era of Pharmaceutical Reason – The Morality of the Circulation of Psychotropics Biological psychiatry, according to Lakoff (2006) was resumed in the 1980s in the USA and from the spread of the first psychotropic drugs.2 The most notorious expression and vehicle of this resumption is not only the publication but also the  The history of the psychotropic industry is not the focus of this chapter. To learn more about the subject and how psychotropics were first used as anti-allergic formulas for after spraying as a medicine that acts to calm soldiers in the Korean and Vietnam wars and how these formulas are born from small laboratories and are appropriate by pharmaceutical industry giants and are normalized as an alternative to alter unwanted behaviours and more recently to provoke desired behaviours and states of consciousness see: Healy 2002, Aguiar and Ortega 2017; Whitaker 2017; Caponi 2019. 2

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spread of the DSM-III as the official merchant of the boundaries between health and mental illness. These limits are no longer built on the environment of the encounter between patient and psychiatrist, but based on formulas and signs established and described in the DSM-III. This manual advertises itself as a-theoretical and presents discussions named as objective of mental disorders based on a classificatory criterion that does not discuss the etiology (Aguiar and Ortega 2017). According to Bourdieu (2006) these actors are successful in naming as technical discussion the immense political effort to erase the power relations involved therein. These relations leave out the context in which this psychic suffering is named as a disease and which brings medicalization as the only alternative to solve problems. It is from the DSM-III that Healy (2002), Aguiar (2002), Whitaker (2017) and Aguiar and Ortega (2017) indicate a true alliance between the pharmaceutical industry and this biological psychiatry.3 According to Corbanezi (2021) and Aguiar and Ortega (2017) this biological psychiatry1997, based on psychotropic drugs, is part of a model of network science or what Latour and Woolgar (1997) named as technoscience4 – science based on technique and technology – involving industry, university, government agency, advertising, doctors, patients. If the definition by Latour and Woolgar (1997) highlighted construction artifacts, placing as a crucial point the political capacity of scientists and/or laboratories to attract funding, today this role has been completely shifted to the hands of the pharmaceutical industry (Ravelli 2015; Mazon 2021). In the age of technoscience, large laboratories train and accompany scientists from the early years of their training process at the university, transforming them into Key Opinion Leaders (KOL), leaders of research initiatives from the pharmaceutical industry. These KOL leaders follow the interests of these companies (Whitaker 2017; Lakoff 2006). Although Latour and Woolgar (1997) highlight inscription artifacts (tables, graphs, spreadsheets, statistics), artifacts that make the data produced mobile, stable and combinable, it is necessary to understand in which environment these data acquire these characteristics, who are the actors and which trajectories allow the legitimation of this new technoscience environment, best expressed as a pharmaceutical reason. Likewise, the spread of the DSM, from its third edition, as a world reference5 allowed not only a cognitive accommodation but also a moral accommodation of these artifacts as more feasible.

 Although this psychiatry is named as biological, it is not linked to any discovery of the biological origin of mental disorders (Aguiar and Ortega 2017: 890). In 2002, in the preparation of the fifth edition of the DSM, this situation had not changed (Aguiar and Ortega 2017: 891). 4  The work of Latour and Woolgar (1997) questions the scientific notion of “discovery”, which presupposes the natural data; the authors show how the production and construction of the scientific fact according to repeated practices in a laboratory. Scientific reality is a consequence and not a cause; it is produced and not discovered, although scientists insist on making the fact a given (Corbanezi 2021:40). 5  Before it was just a diagnostics book like any other previously existing. There was no unity in mental health diagnoses; each organization, institution or association had its own reference manual (Frances 2016). 3

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7.3.1 Psychotropic as Nootropic: Representations of Medication, Expectations about Performance in the Era of Affective Capitalism It is not news that the use of psychotropic drugs has been growing over the last few decades. In Brazil, a study by Prado et al. (2017) found a prevalence of 6.8% in the use of psychotropic drugs among adults. When thinking about specific groups, the prevalence of use of this type of medication is around 20% among university students (Bauchrowitz et al. 2019; Caponi et al. 2021; Morris et al. 2021). This also occurs in relation to nootropics, with studies demonstrating, especially among university students, the use of this type of substance ranging from 8.6% (Cruz et al. 2021) to 44.1% (Pasquini 2013). Several studies show the use of Ritalin and Adderall without medical prescription with the intention and expectation of cognitive improvement. Shillington et al. (2006) note the use of Ritalin and Adderall among college students in Southeast California. These authors found a higher probability of use among students with a low relation of belonging, those who are not committed to a relationship, who smoke or use other drugs. Similar data are found by Teter et al. (2006), by Gloria-­ Garcés et  al (2013) in Chile, Carvalho et  al. (2014), Morgan et  al. (2017) and Campos et al. (2020) in Brazil. The literature that talks about psychotropics for cognitive improvement explores situational aspects that involve the use of these drugs, leaving in the background the broad context in which the option for drug consumption becomes reasonable. In interviews carried out during the research on Psychic Suffering Among UFSC6 Academics, it was possible to verify that some academics, whether at undergraduate or graduate levels, are able to access certain psychotropic drugs through other colleagues who take the medication or who obtain them through illicit means and sell to colleagues. Excerpts from the interviews reveal that university students first report the illegal use and the practice of splitting packs so that the drug can be sold to more than one person: At the beginning of college, I spent the night awake to study. This causes a lot of stress... anxiety crisis...especially when everything is piled up and I can’t organize. Another thing college does. I started taking Ritalin. I got it informally (...) your little friend offers it to you... and you can buy it with someone who found the prescription I don’t know where and buy it for everyone and sell it for you. And it’s like that. I don’t know how he got the prescription, but he was an older boy, he got the prescription, he bought and sold it to this

 The Psychic Suffering project among UFSC students investigated aspects of psychic suffering among undergraduate and graduate students. The first stage involved self-administered questionnaires (Caponi et al. 2021). The objective was to investigate factors associated with psychological distress in university students. The second qualitative stage invited the participants of the first stage for an interview. There were 38 interviews recorded by zoom. The first stage had the participation of a total of 1621 undergraduate and graduate students. The project was submitted and approved by the Ethics Committee for Research with Human Beings (CEP) of UFSC, CAAE number: 4,252,516. 6

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colleague of mine from college (UFSC) and he sold it to us... The box has three packs and he sold each pack for R$70.00. I took one a day because I thought it was what I needed... It seemed like magic... I had a colleague who took three a day. (I.E 2021).

In this excerpt, the student reports the consultation with two psychiatrists until reaching the diagnosis of ADHD and the search for the diagnosis explained by circumstantial issues of academic life: From a very young age, I noticed suffering...I discovered that it was treatable. At the age of 17, I started taking medication under medical supervision. I entered UFSC taking medication (medication for depression). Very happy like that, it was always a dream to enter UFSC, it was a very happy course, but even so, during the course, I went through moments of more intense psychic suffering… 18:45″: In addition to depression I was diagnosed with ADHD. ADHD is a more recent diagnosis. The former psychiatrist thought my inattention was due to depression, but the psychiatrist who came – who is now my psychiatrist – and she is younger too, then she gave me a list to fill in, an interview with family members, and then she diagnosed me with ADHD, that was at the beginning of the year (2021). (...) I take Ritalin because of ADHD and I take Vyvanse together, but then I stopped because of the side effects and venlafaxine for depression and anxiety. (...) Looking back, after a lot of therapy, I was a depressed child, I don’t have siblings, I’m the son of a single mother, I’ve always been kind of like that... ADHD is more recent, I’ve never had hyperactivity problems before, in school. As an adult I’m very inattentive... a lot of subjects in college, I did a lot of electives, which I didn’t need. I think that’s what made me talk to the psychiatrist. (G.B 2021).

Some students report pressure from the high demands of their courses. To meet these requirements, they end up opting for the use of certain substances. In addition, there is still a “social pressure” felt by the students, related to professional success, typical of the formation of the entrepreneur, according to the following reports: “I think it’s pressure from the students themselves. Like... that we have to be successful, anyway, I think it’s a young thing, right? That we have to be successful, graduate from college, get a job and all that. (C.S.A 2021)”. I think there’s a pressure that we don’t necessarily know where it comes from. It doesn’t come from a specific center, it comes from all sides because of the power relations that we live, so I think there is a productivist pressure, for you to produce the best, the best thesis or the best dissertation, for you to win a prize, that you speak several languages, that you are a super person, who knows how to exercise your intelligence, and is recognized; and there is also the pressure of deadlines because we know that the master’s degree, right? Two years is a very short time for you to develop a research. And the scholarship, which is a salary, because you are a worker, you have to deliver the final product of that, of your work, which is also devalued, they do not see us as a professional, as a worker, they see us as a student, as if we lived our whole lives just studying, and not producing, they don’t see it as a job. (F.R.N 2021).

7.4 Final Considerations What this chapter aims to show is this inversion of the meanings of risk, it is possible to observe that in the age of affective capitalism where people occupy the public sphere with problems of the private realm and society is thought in terms of

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the self, the language, which places the psychotropics in circulation contributes to blurring the boundaries between health and mental illness. If it may sound unethical to medicalize people who are not sick, when these medicines are elevated to the status of nootropics the reasoning is reversed: it seems desirable and ethical to be able to allow citizens to improve cognitively, as a way of guaranteeing competitiveness; the diagnosis of a possible disease is in the background. As important as talking about the effects of the increase in the use of psychotropics in today’s society, it is essential to observe the effects of the discourses which put these drugs into circulation on the market through the nootropics label. As it was possible to observe in the aforementioned reports of students, the University environment as a structured and structuring space in the sense proposed by Bourdieu, generates effects on the reproduction of cultural dispositions for the consumption of psychotropic drugs as the demand and pressure for results are perceived by they as unreachable. One of the reports uses the expression “magic” as a problem solved quickly. The decision to consume psychotropic drugs is not exceptional, rather, it is part of everyday practices, where others colleagues make similar decisions.

Bibliographic References Aguiar, A.A. 2002. A psiquiatria no divã. Entre as ciências da vida e a medicalização da existência. Rio de Janeiro: Relume/Dumará. Aguiar, M.P., and F.V.G. Ortega. 2017. Psiquiatria biológica e psicofarmacologia: a formação de uma rede tecnocientífica. Physis 27 (4): 889–910. Bauchrowitz, C. et al. 2019. Prevalência de uso de psicofármacos por acadêmicos: efeitos do processo de graduação. Braz Jof Develop 5(11), 24,915–24,933. Bourdieu, P. 2006. As estruturas sociais da economia. Trans. Ligia Calapes and Pedro Simões. Porto: Campos das Letras. ———. 2009. O senso prático. Rio de Janeiro: Vozes. Brzozowski, F.S., and P.K. Daré. 2021. Criando crianças para um mundo competitivo: o uso do metilfenidato para o aperfeiçoamento do desempenho na infância. In Saberes expertos e medicalização no domínio da infância, ed. Sandra Caponi et al., 203–222. São Paulo: LibersArs. Cabanas, E., and E. Illouz. 2019. A ditadura da felicidade. Como a ciência da felicidade controla nossas vidas. Lisboa: Bertrand. Campos, P.C., et al. 2020. Uso Indiscriminado de Ritalina® por estudantes universitários do Norte do Paraná, Brasil. Braz JHeaRev. 3(5),14,690–14,696. Caponi, S. 2019. Uma sala tranquila. Neurolépticos para uma biopolítica da indiferença. São Paulo: LiberArs. Caponi, S., et  al. 2021. Sofrimento psíquico em acadêmicos da Universidade Federal de Santa Catarina. In Relatório de Pesquisa. NESFHIS/UFSC. Florianópolis: UFSC. Carvalho, T.R.F., et al. 2014. Exigências de produtividade na escola e no trabalho e o consumo de metilfenidato. EducSoc 35 (127): 587–604. Conrad, P. 2007. The medicalization of society. On the transformation of human conditions into treatable disorders. Baltimore: The John Hopkins University Press. ———. 2013. Medicalization: Changing Contours, Characteristics, and Contexts. In Medical Sociology on the move. New directions in theory, ed. W.  Cockerham, 195–214. Dordrecht-­ Heildelberg: Springer.

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Conrad, P., and V.  Leiter. 2004. Medicalization, markets and consumers. Journal of health and social Behavior 45: 158–176. Corbanezi, E. 2021. Saúde mental, depressão e capitalismo. São Paulo: Editora Unesp. Coveney, C., et al. 2011. Enhancement imaginaries: exploring public understandings of pharmaceutical cognitive-enhancing drugs. Medicalization and beyond. Health Sociology Review 20 (4): 381–393. Cruz, T.C.S.C., et al. 2021. Uso não prescrito de metilfenidato entre estudantes de medicina da Universidade Federal da Bahia. Gazeta Médica da Bahia 81 (1): 3–6. http://biblioteca.cofen. gov.br/desafio-­global-­seguranca-­paciente-­medicacao-­sem-­danos/. Accessed 2 April 2022. Dardot, P., and C. Laval. 2016. A nova razão do mundo: ensaio sobre a sociedade neoliberal. São Paulo: Boitempo. Fourcade, M., and K. Healy. 2017. Seeing like a market. Socio-Economic Review 1 (1): 9–29. Frances, A. 2016. Voltando ao normal: como o excesso de diagnósticos e a medicalização da vida estão acabando com a nossa sanidade e o que pode ser feito para retomarmos o controle. Rio de Janeiro: Versal Editores. Fridman, D. 2019. El sueño de vivir sin trabajar: Una sociología del emprendedorismo, la autoayuda financiera y el nuevo individuo del siglo XXI. Buenos Aires: Siglo Veintiuno Editores. Gloria-Garcés, C., and K.G.G. Vedana. 2013. Consumo de estimulantes del sistema nervioso central en estudiantes de enfermería y medicina de una universidad chilena. SMAD, Rev Eletrônica Saúde Mental Álcool Drog 9 (2): 64–69. Healy, D. 2002. The creation of psychopharmacology. Harvard: Harvard College. Illouz, E. 2011. O amor nos tempos do capitalismo. Rio de Janeiro: Zahar. ———. 2019. L’ideal de la santé mentale et de amelioration de soi. L’auto-contrôle emotionel comme marchandise. In Les marchandises emotionnelles. L’autenticité au temps du capitalisme, ed. E. Illouz, 194–338. Paris: Editions Premier Parallele. Lakoff, A. 2005. Pharmaceutical reason. Knowledge and value in global psychiatry. Cambridge: Cambridge University Press. ———. 2006. High Contact, gifts and surveillance in Argentina. In Global Pharmaceuticals. Ethics, Markets, Practices, ed. A. Petryna et al., 112–135. Durham-London: Duke University Press. Latour, B., and S. Woolgar. 1979/1997. Vida de laboratório: a produção dos fatos científicos. Rio de Janeiro: Relume-Dumara. Mazon, M.S. 2019. Indústria farmacêutica e psiquiatria no quadro da Sociologia Econômica: uma agenda de pesquisa. Política & Sociedade 18 (43): 136–161. ———. 2020. Dos diagnósticos aos manuais: mercado farmacêutico e transtornos mentais da infância em questão. Política & Sociedade 19 (46): 115–140. ———. 2021. Por que a indústria farmacêutica é diferente das outras? Saúde mental, ciência e psicotrópicos em questão. In Saberes espertos e medicalização no domínio da infância, ed. S. Caponi et al., 33–52. São Paulo: LiberArs. Morgan, H.L., et al. 2017. Consumo de Estimulantes Cerebrais por Estudantes de Medicina de uma Universidade do Extremo Sul do Brasil: Prevalência, Motivação e Efeitos Percebidos. Revista Brasileira de Educação Médica 41 (1): 102–109. Morris, M.R., et al. 2021. Use of psychiatric medication by college students: A decade of data. Pharmacotherapy 41: 350–358. Moynihan, R., et al. 2002. Selling sickness, the pharmaceutical industry and disease mongering. British Medical Journal 324 (7342): 886–891. Pasquini, N.C. 2013. Uso de metilfenidato (MFD) por estudantes universitários com intuito de “turbinar” o cérebro. Biofar 9 (2): 107–113. Petryna, A., et al. 2006. Introduction. In Global Pharmaceuticals. Ethics, Markets, Practices, ed. A. Petryna et al., 206–239. Durham-London: Duke University Press. Pochmann, M. 2020. Tendências estruturais do mundo do trabalho no Brasil. Cien Saude Colet 25 (1): 89–99.

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Portugal, D., and Vaz, P. 2012. A felicidade é química e pode ser vendida? As dimensões éticas e farmacológicas da razão farmacêutica. https://proceedings.science/compos-2012/papers/ a-­felicidade-­e-quimica-e-pode-ser-vendida--as-dimensoes-eticas-e-mercadologicas-da-razao-­ farmaceutica#. Accessed 2 April 2022. Prado, M.A.M.B., et al. 2017. Uso de medicamentos psicotrópicos em adultos e idosos residentes em Campinas, São Paulo: um estudo transversal de base populacional. Epidemiol Serv Saude 26 (4): 747–758. Ravelli, Q. 2015. La stratégie de la bactérie. Une enquête au cœur de l’industrie pharmaceutique. Paris: Seuil. Rose, N. 1996. Psychiatry as a political science: advanced liberalism and the administration of risk. History of the human sciences 9 (2): 1–23. ———. 2006. The Death of the social? Refiguring the territory of Government. Economy and Society 25 (3): 327–356. ———. 2013a. A política da própria vida: biomedicina, poder e subjetividade no século XXI. São Paulo: Paulus. ———. 2013b. The human science in a biological age. Theory, Culture & Society 30 (1): 3–34. ———. 2019. Our psychiatric future. Cambridge: Polity Press. Schermer, M., et al. 2009. The future of psychopharmacological enhancements: Expectations and policies. Neuroethics 2 (2): 75–87. Shillington, A.M., et al. 2006. College Undergraduate Ritalin Abusers in Southwestern California: Protective and Risk Factors. Journal of Drug 36: 999–1014. Teter, C.J., et  al. 2006. Illicit use of specific prescription stimulants among college students: Prevalence, motives, and routes of administration. Pharmacotherapy 26 (10): 1501–1510. Weber, M. 2004. Economia e Sociedade. Fundamentos da Sociologia Compreensiva. São Paulo: Ed UNB, Brasília/Imprensa Oficial do Est. de São Paulo. Whilliams, J.S., et  al. 2011. The pharmaceuticalisation of society? A framework for analysis. Sociology of Health & Illness 33: 710–725. https://doi.org/10.1111/j.1467-­9566.2011.01320.x. Whitaker, R. 2017. Anatomia de uma pandemia: pílulas Mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz. Zelizer, V. 1978a. Human values and the market: the case of life insurance and death in nineteenth-­ century America. American Journal of Sociology 84 (3): 591–610. ———. 2011. Economic lives: how culture shapes the economy. Princeton: Princeton University Press. ———. 1978b. Human values and the market: the case of life insurance and death in nineteenth-­ century America. American Journal of Sociology 84 (3): 591–610.

Chapter 8

The Body in O Cemitério dos Vivos by Lima Barreto: An Aesthetic Phenomenological Reflection on the Practice of Norms Ana Paula Barbosa-Fohrmann

and Marcelo Fabri

Abstract  This chapter deals with two philosophical interpretations of a novel intitled O Cemitério dos Vivos by Lima Barreto, an Afro-Brazilian author of the early twentieth century. These interpretations are anchored in Merleau-Ponty’s and Levinas’s phenomenologies. This chapter intends to analyse how psychiatric, legal and moral norms were applied to the main character with psychosocial disability and to other subjects locked up in a psychiatric hospital in Rio de Janeiro. Keywords  Narrative · Work of art · Psychiatric hospital · Experience · Phenomenology of the body · Practice of norms · Vulnerability

The spectacle of madness, not only in the isolated individual but, above all, in a population of asylums, is one of the most painful and sad spectacles that can be offered to those who lightly meditate on fate... (Lima Barreto).

8.1 Introduction The phenomenological approach to the body, since Husserl, has underlined and explored, with enormous fecundity and mastery, the freedom of the subject dealing with the constitution (Konstitution) of the world. Sensitivity, understood from the point of view of the psycho-organic body (Leib) in its concrete relations with the

A. P. Barbosa-Fohrmann (*) Department of Legal Theory, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil e-mail: [email protected]; http://lattes.cnpq.br/4012995260619181 M. Fabri Department of Philosophy, Federal University of Santa Maria, Santa Maria, RS, Brazil; http://lattes.cnpq.br/9122803302644811 © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_8

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world and with others, is the basis of all Husserlian discussion about the constitution. All orientation in the world depends on a sensitive situation, in which the body is the zero point of our thinking, acting and living. But the human being is not just rationality or rational motivation. Leib is also the place where dynamics of subjection and frailties occur all the time. Madness, suffering, loss of motivation for life are always reminding us of the weakness of our good conscience. Furthermore, thanks to this weakness, human beings can at any moment find themselves imprisoned and domesticated by various forms of oppression and power, such as those at work in the institution called the asylum. In such painful extreme situations, however, a powerful force can emerge. Madness, which causes us astonishment and horror, and makes us see life in its darkest aspects, emerges as a condition for an awakening: the human as attention and guidance to the other. The human, in our perspective, brings together the discussion of two very different phenomenologists: Merleau-Ponty and Levinas. Both are heirs of Husserl, but they were very attentive to the contributions of art in their reflections (let us remember that they were avid readers of Proust, a writer who had an enormous influence on both). They explore the ambiguity of the psycho-­ organic body, emerging as the protagonist of a paradoxical situation: the human in us is a living sensibility which, despite being subjected to structures of power and oppression, is capable of discovering ties with the whole of humanity. Solidarity erupts in us, without having had time for any reflection or decision about it. We feel close to so many lives that are on the threshold of lucidity and madness, of meaning and non-meaning. Proximity that, in his work O Cemitério dos Vivos (The Graveyard of the Living), Lima Barreto narrates with the vigor of a genius who lived the experience of mental illness firsthand. Phenomenology, once again, benefits from literature to describe the power that situations of extreme obscurity and vulnerability (in this case, madness) have to describe the psycho-organic body involved in the abuses of institutions that, in theory, should have the role of looking after the health of so many human beings in situations of fragility.

8.2 Narrative: Lima Barreto’s O Cemitério dos Vivos O Cemitério dos Vivos (The Graveyard of the Living) is a novel from the beginning of the twentieth century, written by the Afro-Brazilian author Lima Barreto in 1919 and 1920. The novel results from a great deal of entries made in his diary from the same period, insofar as he recounts his experience in a Rio de Janeiro asylum. The novel, therefore, although fictional, is narrated in the first person and has confessional characteristics. It deals with Vicente Mascarenhas’s moral and psychological drama, married and with a child. According to the character’s opening words:

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The best thing is to tell how my marriage was, a bit about my life, so that we can understand why this domestic spectacle, usually of so little importance, has brought me profoundly painful consequences, a true psychological and moral drama, which all the later satisfactions, work and vice, could not put an end to in my conscience (...) (Lima Barreto 1993, p. 97, own translation).

At the age of 17, Mascarenhas became a civil servant and began to live in a boarding house, where he met Efigênia, the owner’s daughter: Like everyone else, I wanted to be a ‘doctor’ in something. Without a sponsor for my studies, at the age of seventeen, with a false age certificate, I did a public service exam and I took up a low position as a civil servant. (...) I didn’t much like when I came across a girl a little younger than me at the boarding house, living familiarly with the customers. It was Ms. Efigênia, the landlady’s daughter, who supervised service in the dining room. (Lima Barreto 1993, p. 98, own translation).

Despite understanding marriage as antagonistic to his own work (of art), which was his life, he married her reluctantly some time later: - I love you, Mr. Mascarenhas; do you want to marry me? I expected everything but such a question. I immediately saw the disadvantages of marriage. I would be imprisoned, I would not be able to freely carry out my life plan, I would flee my destiny because of the duty to support my wife and future offspring. Over the years the need for money would grow; and I would then have to apply for offices, promotions, whether trained for them or not, and I would have to have patrons and protectors, whom I should not offend lest I appear ungrateful. Where would my dream of glory be, even if it was just of demolition? Where would I hide my ‘youthful thinking’? I would suffer a lot for running away from it... Besides, even if I managed to get closer to achieving what I planned, my marriage was the negation of my own work. (Lima Barreto 1993, p. 117–118, own translation, emphasis is ours).

After their wedding, Mascarenhas’s life was tainted by some tragic events, which disturbed him to the point that he was taken to the asylum for alcoholism: Married, as I have already said, with so many intimate reservations, I lived for five years with my wife, until her death, in the most perfect peace of domestic decency. Right after my first year of marriage, the birth of my first and only child... It was after Efigênia’s death that my thoughts ran wild, leading me twice to the asylum. (Lima Barreto 1993, p. 130, own translation).

Further: I was in my early thirties, with a fatally illiterate son, a crazy mother-in-law, I myself with a reputation for being a drunkard, tolerated in the office that annoyed me, poor thing, I saw life as a dead end. A youngster, I could not appeal to my youth; cultivated, I could not assert my cultivation; polite, I was taken for a vagabond by the whole world and suffered the greatest humiliations. Life had no more flavor for me and it seemed that hope had abandoned me. After drinking consecutively for a week, one night, I woke up screaming in the morning and the next day I spent so full of terrors that my nephew André, who already worked and helped me a great deal, had no choice but to ask the police to take me to the asylum. This was the first time. (Lima Barreto 1993, p. 140, own translation).

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8.3 An Interpretation of the Living Body as a Work of Art in O Cemitério dos Vivos Grounded in Merleau-Ponty Based on the episodes narrated by Mascarenhas (so to speak, Lima Barreto’s alter ego), in this regard, we will explore a paraphrased fragment of the main character that the subject’s life is a work of art according to our interpretation of Merleau-­ Ponty’s phenomenology. The body is intentional motor consciousness, which means it is living body, also considered by us as body-subject, grounded in Merleau-Ponty’s view. This is so because the body is understood as psycho-organic. It is the body that, by intentionally moving towards certain things in the world of concrete life, becomes intentional motor consciousness of these objects. It is during this intentional movement in the corporeal space, that is, within a certain specific field of sensations experienced by each human being, taken one by one in his particularities, that the body becomes living body or body-subject. That human being thus becomes a subject who does not have a body as an instrument, a property, but as a subject who is a body. It is the body as a subject that feels, remembers, acts, moves, desires, thinks and decides. It is the body that through tactile, visual, auditory, gustatory and olfactory sensations perceives or experiences the world of concrete life. It is the body that shows itself as a phenomenon in that world. For Merleau-Ponty, the body is comparable to the work of art in the sense that the body becomes a subject when it plays a piece on the piano, when it sings an opera piece, when it paints a picture like Cézanne, when it remembers the past dipping a madeleine in a cup of tea, like Proust in Remembrance of Things Past (2005; 2016), and describes its sensations in a narrative. Specifically the body-subject or living body paints and transforms the world into paintings through vision and movement. The living body is in the world and things are around it as its extension.1 Because things are embedded in its flesh, they define it in its fullness. Both are made of the same stuff, which means living body’s vision is, on the one hand, produced in things, and things, on the other hand, manifest the vision. The living body sees things and is seen by them and things see the living body and are seen by it. The world is then made up of the same stuff as the living body. This is to say that “vision is caught or comes to be in things - in that place where something visible undertakes to see, becomes visible to itself and in the sight of all things…” (Merleau-Ponty 1964b, p. 19–20, own translation). Since the living body and things are made of the same stuff, the vision is already in things and is manifested by them. The living body repeats this vision of things, ie. the vision that is in the things of the world. Light, lighting, shadow, reflections,

 We employ the pronoun ‘it’ in order to refer to the living body or body-subject or even psychoorganic body grounded in Merleau-Ponty’s theses. Compare Barbosa-Fohrmann (forthcoming). 1

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tones, colours, depth see and are seen by the living body Cézanne,2 for instance, which welcomes them, returning to the world, through brush strokes, the same or at least a similar vision that things in the world manifest. Merleau-Ponty remarks that it would be difficult to tell where the painting he is looking at is. This is because he does not look at it as something fixed in one place, but rather as something that manifests to him, which sees his gaze moving over it, which sees him seeing it. He repeats and follows the vision that the painting has, seeing what the painting makes him see. (Merleau-Ponty 1964b, p. 23). The body intertwines with the work of art itself, there being, in our interpretation, no separation between, for example, the body-subject that paints and what was painted by it, that is, between subject and object, between, therefore, subject and work of art. In other words, the work is already anticipated as a finished work, that is to say, a finished work is already made in its own construction, in the very act of painting. Furthermore, in our interpretation of Eye and Mind, the work itself is subject, not object, not only by virtue of the fact that it intertwines with the subject who paints it or sees it in a museum, but also by virtue of the fact that the painting, for example, attracts (as an active pole, as a subject) those who see it (as a passive pole, also as a subject). Things and the world entered Cézanne and became a gesture, a movement, a trace on the canvas. The painter embodied, then, things and the world. Cézanne’s embodiment of nature occurred – throughout his career – by means of seeking depth and colour in germination, of seeking tone, texture and dimension that could identify a mountain as a mountain. To see this germination means to see directly the Mountain of Saint Victoria in its element, that is, as rock above Aix-en-Provence, as it manifests itself in its aspects (light, shadows, texture, height, distance) that show and hide a side, an aspect in a certain moment or instant of the day. Cézanne revealed, then, by gesture and stroke, the identity of that mountain, but also of a fruit in a basket and of a woman bathing in a river. And this gesture that ends in a stroke is an emanation of these very things, an extension of them. Cézanne declared that “the landscape thinks itself in me”, and Merleau-Ponty quoting Cézanne, adds “and I am its consciousness” (Merleau-Ponty 1964a, p. 17). It is also in this sense that we say that the relation between Cézanne and the nature he painted manifested itself as a relation between subjects, between two intentional consciousnesses towards each other, that attracted the movements of one another. From a Merleau-Pontian perspective, it is not a relation between subject and object, the subject who paints in relation to the nature he painted, but rather, between the body-subject painter in relation to the body-subject painting (ie. the painted nature), insofar as the latter attracted Cézanne to execute it the way it showed itself, with a certain light, a certain texture, a certain shading, a certain distance. Once again, between the body that paints and the body that is a painting, there is an intertwining of two subjects (ie.  We use the expression ‘living body someone’ or ‘body-subject someone’, and not ‘someone’s living body’ or ‘someone’s body-subject’. This is because we understand that body and subject constitute an identity, or, are one and the same. The body is not in this sense someone’s property. Compare Barbosa-Fohrmann (forthcoming). 2

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chiasma), that is, they mingle not only because painter and painting are constituted of the same flesh, but also they show themselves as interwined in the same flesh, which is the same world of concrete life (Merleau-Ponty 1969). In O Cemitério dos Vivos, Mascarenhas’s marriage became the negation of his life as a narrative work under construction, in which he would become famous for his intellectuality and his published books (Lima Barreto 1993, p. 140, own translation). His book was indeed published, but at the end of his marriage, that is, with the death of his wife Efigênia (Lima Barreto 1993, p. 139, own translation), and this was what comforted him: My solace was my book. The signed review, the person who wrote it, that honored my book greatly, particularly people above good and evil expressly praised the book. They whispered about the book, and I sensed in the air the emotion and surprise it had caused. I should have rejoiced, but the joy it could bring me was drowned out by my money difficulties and my mother-in-law’s illness. (Lima Barreto 1993, p. 139, own translation).

However, his life was marred by the loss of his wife, his son to raise, his mother-in-­ law’s madness and his own drunkenness. The narrative of a promising future became empty, lost meaning. His life as a great work of art reached an endpoint. We quote: I felt an inner despair, an annoyance at myself, a sign of my obvious incapacity for any greater work, because – I reasoned – whoever had a human being at his side lived with him in the most total intimacy in which two human beings can live, did not understand him, cannot understand anything else at all. And I threw my books to the side, and I started drinking, (...) and I wanted to cancel myself out, to drop out, a clod of mud for the police to kick (Lima Barreto 1993, p. 145, own translation).

Although Mascarenhas argues that his life became the negation of his work (Lima Barreto 1993, p. 118), the fact is that he continued to construct his narrative based on psychic suffering. He continued to tell his story about the grievous events outside the asylum and the equally or more painful events inside it. In other words, Mascarenhas, as a subject who tells his life story and as the alter ego of the author Lima Barreto, merges with his work. His narrative to be written needed a life like his, with its pains, losses and sufferings. The artwork here, which is the narrative of Mascarenhas’s psychic suffering, is confused with the character, who writes it in the first person, in a confessional and cathartic way. Describing the experience of writing, we can argue that Macarenhas was attracted by the pen and the sheet of paper to tell his story. Likewise, the pen and the sheet of paper were attracted to that character with that personality and private life. That is why both the character Mascarenhas and the work written by him - O Cemitério dos Vivos - are subjects. They are active poles that attract and relate to each other. We, as readers, know two subjects: first, the work O Cemitério dos Vivos, then we know Mascarenhas (alias Lima Barreto). Merleau-Ponty makes a similar point. Cézanne, whose life was marked by crises of anger, anxiety, depression, and difficulty in establishing contact with other people, made painting ‘his way of life’ (Merleau-Ponty 1964a, p. 9). It seems to us that the germ of Cézanne’s life was in his work. This is because we know his work first and we see through it his schizoid temperament and the circumstances of his life.

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“The truth is that that work to be done called for that life. From the very start, Cézanne’s life found its only equilibrium by leaning on the work that was still in the future. His life was the preliminary project of his future work”. (Merleau-Ponty 1964a, p. 20, emphasis is ours). Undoubtedly, here, as in Lima Barreto’s literature, there is an intertwining between author and work, between, therefore, two subjects.

8.3.1 Between Moral and Psychiatric Norms: The Body-­Subject’s Experience as a Work of Art in a Psychiatric Hospital The body-subject as a work of art is shown in O Cemitério dos Vivos in the intertwining of two subjects: author-character and narrative. With a specific focus on the body-subject character (Mascarenhas) intertwined with the body-subject author (Lima Barreto), we understand that, as already mentioned, the intertwining occurs because it is a first-person narrative and of a confessional and cathartic nature. We interpret it this way, because this novel was directly grounded in O Diário do Hospício, which was written by Lima Barreto when he was hospitalized in the asylum. Both O Cemitério dos Vivos and O Diário do Hospício are from the same years 1919–1920. The make-believe ‘as if I were...’ that is evident in the fictional narrative is thus intertwined with the real-life ‘as I am’ of the non-fiction one that motivated the latter. The living body or body-subject Mascarenhas, an Afro-Brazilian character, acts like an alcoholic and hallucinating. Therefore, it is hospitalized like a madman in an asylum, which it describes as a prison. In its own words: The habit of drinking returned to me, and this time, penniless, poorly dressed, feeling the catastrophe of my life approaching, I was driven to strong and apparently cheap drinks, the ones that intoxicate the fastest. I went from whiskey to genebra, to gin and, from there, to cachaça. (Lima Barreto 1993, p. 139, emphasis is ours, own translation).

Further: When, for the first time, I was taken to the asylum, my crisis was in fact profound and required me to withdraw from my usual environment, in order to cleanse myself of the hallucinations that alcohol and other factors had caused. They lasted the next few days; but when I arrived at the pavilion, I was almost myself and I did not have the slightest mental disturbance. When I got there, they took off the clothes I was wearing, they gave me one from the ‘house’, as they say there, I formed a line alongside other lunatics on a balcony, they gave me a mug of mate and grain and, after having had that evening meal, they put me in a strong room. Until then, despite having undressed me in full view of everyone  – something that always displeased me – I had no reason to complain; but that strong room brought tears to my eyes. My childhood dreams had resulted in that. There, I don’t know why, I remembered my dead wife, whose memory delirium had driven from my mind; I gained more strength and entered that useless prison more confidently (...) (Lima Barreto 1993, p. 123, emphasis is ours, own translation).

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It is in the asylum (ie. prison) that Mascarenhas reports the deepening of psychic suffering and the emptiness of the meaning of life. One of the horrors of any seclusion is that you can never be alone. In the midst of that crowd, there is always someone who comes to tell us this or that. At the asylum, I felt this discomfort that can only be understood by those who have already found themselves confined to a prison; there, however, it is worse than anywhere else, especially when you are perfectly lucid, as I was. (Lima Barreto 1993, p. 166, own translation).

His report does not only focus on his own pain, but also on the pain of the entire community of insane people (immigrants, blacks, workers, children under 10 years old, demented, turbecular, epileptic, Lima Barreto 1993, p. 143, 154–155), which ends up, through the voice of Mascarenhas, narrating the plot of the spectacle which they are part of: the spectacle of madness. We quote: It was in such a state of mind, penetrated by a profound intellectual nihilism, that I entered the asylum for the first time; and the gross painful spectacle of madness further ingrained in my spirit this conception of a misty world, almost plunged into darkness, leaving only suffering, pain, misery, and sadness involving everything, sadness that nothing can beat or lessen. (Lima Barreto 1993, p. 130, own translation).

Socially segregated (Lima Barreto 1993, p. 123), the majority of the insane community is made up of obedient and docile bodies, which, with the passage of time of incarceration, lost their subjectivity. They became body-objects. But a small part, Mascarenhas says, is made up of rebellious and unbearable individuals, either because of their gestures, their actions or the consequences of their mental illness. (Lima Barreto 1993, p. 164). Like Mascarenhas, whose narrative shows that he is lucid, the other madmen who rebel against institutionalization reveal themselves, according to Mascarenhas’s interpretation lines, as body-subjects that are not undermined by psychiatric structure and its institutional norms. The lucidity without revolt, and the lack of lucidity described as revolt show that those incarcerated resist the objectification of their bodies. Lucid or not, we believe in the narratives that show some kind of resistance to intramural norms, which indistinctly imprison, bodies-subjects from marginalized social strata for understanding that they are not intentional consciounesses, that is, living bodies or body-subjects. According to our interpretation of Merleau-Ponty’s view, the pure essence of consciousness effected by cogito discards and, therefore, does not know or understand other modes of consciousness. Each subject carries out the cogito. In Merleau-­ Ponty’s terms, the lunatic is not mad he thinks he is. In fact, the meaning of madness is unified by the pure cogito, as it identifies all ‘diseases’ as ‘the same disease’. This is the rationalist view (Merleau-Ponty 2002, p.  144; Barbosa-Fohrmann, forthcoming). Physicians, psychiatrists and psychologists do not share the universalizing and unitary vision of intellectualist consciousness and return, as a result, to empirical causes, which have only one advantage: they take into account what is particular about each disease. For modern pathology, there is not ‘the’ disorder because there is not ‘the’ consciousness. Both one and the other are nuanced according to the

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particularity of the behaviour (language, perception and action) that it affects (Merleau-Ponty 2002, p. 145; Barbosa-Fohrmann, forthcoming). We understand that the lunatic thinks he is so because in most cases in the novel he does not know why he is empirically classified as a lunatic and locked up (ie. segregated) by psychiatrists in an asylum. In other words, psychiatry affirms he is mad inasmuch he is poor, black, a factory worker, an immigrant and so forth. This incarcerated or institutionalized individual, when doubting his sanity in the hospital space and over time, ends up, on the one hand, believing that he is in fact a lunatic like everyone else (universalization of the rational or intellectualist view). On the other hand, the hospital’s medical structure also understands his particular case (particularism of the empirical view) as being one of insanity, which also reinforces or confirms his own doubt. The administration of the asylum is carried out in sections and pavilions, at the head of which there is an alienist and more doctors. From what I understood, there are four main sections of the asylum: Pinel and Calmeil, for men; and Morel and Esquirol, for women. In addition to these, there are other special ones, for epileptics, for retarded, healthy and epileptic children, for tuberculosis patients, etc., each with a name of a national or foreign authority. The pavilion, par excellence, is the observation one, which has a sui generis organization, and depends on the asylum, the police and the Faculty of Medicine, whose head of psychiatry is its director, without any dependence or subordination to the head of the asylum.The rest of the lower-level staff, however, depend on him and provide this establishment with everything else. (Lima Barreto 1993, p. 176, own translation).

As we argued above, the subject, when doubting his sanity and accepting his diagnosis, ends up becoming docile, by becoming an object. The others, who resist the condition of institutionalization, are rebels in some way, whether by physical acts of violence, understood as such by the structure of the psychiatric hospital, or by intellectual acts, as is the case of Mascarenhas, the main character of Lima Barreto’s novel. Once again, the body-subject character (Mascarenhas) linked to the body-subject author (Lima Barreto) is body as a work of art. The body-subject is shown through reported experience. It lives in the midst of moral norms that define madness as generalizable, that is, as presenting itself in every human being, for it is hereditary. This presentation of the experience of madness as an infraction of certain moral norms and of psychiatric ones (hereditary infraction) is evident in this passage: To generalize about its background [of madness] would be wrong at base. Moral shocks, deficiency of intelligence, education, instruction, vices, all these causes determine varied and different forms of madness; and sometimes none of them are. An appeal is made to heredity, which can both be a cause of some as well as of others; and that, if it were to exercise its power so despotically, there would not be a single reasonable person on Earth. It is enough to think that we are like heirs of thousands of grandparents, in each of us we find their blood, their defects; inevitably, in such a multitude, there must be those who have gone off the rails, addicts, etc. Therefore, heredity will not carry much weight only on this and that one, whose antecedents are known, but on all of us... (...) The explanation by heredity is convenient, but perhaps illogical... (Lima Barreto 1993, p. 148–149, own translation, emphasis is ours).

Further:

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Mascarenhas also tells what it is like to be educated, but to be considered morally a vagabond, since the moral infraction of being the son of an illiterate person, having a reputation as a drunk, and of being poor is psychiatrically hereditary. This tension between being educated, enlightened and not being morally considered as such and, therefore, psychiatrically so as well, we take from this excerpt: I was in my early thirties, had a fatally illiterate son, an insane mother-in-law, I myself had a reputation for being a drunk, I was tolerated in the office that annoyed me, poor, I saw life as a deadend. Young, I could not appeal to my youth; cultivated, I could not assert my cultivation; educated, I was taken for a waster by the whole world and suffered the greatest humiliations. Life had lost all flavor and it seemed that hope had abandoned me. (Lima Barreto 1993, p. 140, own translation).

Mascarenhas, as a body-subject, shows that its experience is one of guilt, which induces it to be aware of the moral-psychiatric infraction it committed, namely, the addiction to drinking. This inculcated experience of guilt that occurs in the context of the psychiatric hospital makes us think about whether Mascarenhas in fact became docile and resigned to his condition, which, in our interpretation, made him a body-object. In these passages, this possibility of reducing his subjectivity to the condition of an object is evident: “My feeling was no longer one of hurt and pain from being there; it was of hope of my correction and the improvement of all men” (Lima Barreto 1993, 152, own translation). And further: My conscience, the certainty I had that I was the one to blame for being there, that and my weak will, which, however, was strong in other ways, forced me, out of my moral decorum, to ask nothing of comrades to make things easy for me. For the rest, I had already gotten what was reasonable for an ordinary man who was taken to a public hospital like a tramp. Far from accusing others, far from censuring the unknown and semi-unknown with whom I dealt with this social classification, I only had good things to say about them, because, judging me like that, they didn’t offend or mistreat me at all. The little things that hurt my self-esteem and that disgusted me intimately were the result of the way I was going through life, letting myself fall, annihilating myself. It is now curious to note that what impressed me most in the insane people was the depressive mania, it was the effects of the illness leading the individual to the forgetfulness of his body, of his dignity as a man, of the obliteration, if not erasure, of all external manifestations of his soul, of his life... (Barreto 1993, p. 156–157, own translation, emphasis is ours).

At the same time that Mascarenhas accepts the ‘correction’ of his ‘guilt’, which, by itself, we would say that he shows himself as a body-object, he, however, does not see himself as an insane man, since the others, opposed to him, forget their bodies

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and their dignity as men; they indeed let themselves be erased. This reflection of the character deals precisely with the process of objectification of the other, which he does not recognize in himself. This reflection is therefore ambiguous. He, by confirming the insane men’s total subjection to moral and psychiatric norms, which makes them body-objects, seems to mean that he himself is not becoming an object like the others. This non-mirroring of himself in others makes us think that he is a body-subject, as he does not identify with the condition of subjection and objectification that the moral-psychiatric condition attributes to the insane. On the other hand, the question remains whether Mascarenhas really feels guilty, and that he needs moral-psychiatric correction, which would lead us to interpret his narration as that of a subject who conforms, becomes docile, lets himself be objectified. In our interpretation, however, the entire narrative is one of resistance even to the segregation of the psychiatric hospital. The character feels guilt and he understands that his actions should be corrected. By writing, he shows sarcasm and nonconformity with his condition of isolation within walls. Mascarenhas or Lima Barreto is a body-­ subject that rebels through its narration.

8.3.2 Among the Obligation, Prohibition and Permission of Moral and Psychiatric Norms: The Body-Subject Experience as a Work of Art Body as a work of art appears through the experience specifically in the tension (or ambivalence) between the prohibition and non-prohibition (permission) of moral and psychiatric norms. The first time, I didn’t leave the pavilion to go to that section, which is for the poor, but, in which, out of consideration, the kindness of the administration can place, without violating the regulations, many who were not poor. So, when I left the pavilion, and went to the section, the second time, it was a new, unprecedented, dense spectacle, which I was forced to watch there. (Lima Barreto 1993, p. 141, own translation).

In the pavilion, there are the so-called ‘indigents’, who were morally and psychiatrically classified ‘like this’ or ‘like that’ They are obliged to remain in that place according to the regulation. But there are also those not classified as indigents. Those who should in accordance with the regulations be allocated to another part of the hospital, they are, however, left in opposition to the regulations in the same pavilion. It is the moral and psychiatric norms that determine an ambivalent behaviour in those who exercise an administrative function in the psychiatric institution, who sometimes become familiar with the ‘patients’, treating them as ‘you’, or use formality with the ‘patients’ with some academic training: Life, in general, among the sick and guards, is of the closest familiarity. Insane people treat their guards as you and they treat the demented the same way. They only make exceptions,

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It is the institutionalized community, also in partnership with the guards, that cleans the institution: The corridors, halls and rooms are waxed and, in the morning, before and after breakfast, in partnership, employees and patients wax the floor, and scrub it with brushes attached to large stumps of heavy wood or to the feet by ties. Friction between guards and patients is rare, but it does exist, because many of the latter are quite unbearable, and some guards are impatient, out of fatigue or temper; but, in general, relations are friendly. (Lima Barreto 1993, p. 165, own translation).

The institutional rules of obligation to do or not to do are, therefore, ambivalent in the sense that they can be circumvented depending on the relationship of familiarity in that community made up of ‘lunatics’ and hospital staff It is to be assumed that this softening of the mandatory rules comes from the administrative authority, whether a guard or someone on duty, who, having to exercise it, chooses not to, as is the case of the daily cleaning of the hospital. The same kind of tension, ambivalence, obligation to follow psychiatric norms and their non-obligation, the line between what can be done with an inmate and what is prohibited is present in Mascarenhas’s experience with his doctor. I feel, I don’t know why, in this young man, a great love for novelty, a very unscientific speed and haste in trying out the “new medicine” (...) This lack of method, together with my wretched condition, made me fear that he would try to experiment on me with a new process of curing alcoholism in which a sensitive and dangerous operation would be used. For the first time, fundamentally, I felt doom and doomed. I had lost all social protection, all right over my own body, I was just like an anatomy corpse in an amphitheater. Fortunately, I was soon transferred, but not without spending painful minutes waiting to fall victim to this mental addiction to our methods. Few logicians, who are therefore too objective, impatient and accepting of “authority” all over the world, risk in good faith committing the grossest and most disastrous mistakes in the exercise of their profession. They lack criticism, not only the most common, but also the necessary one of the degree of certainty of the experience and of the instruments in which they remake them. (Lima Barreto 1993, 175, own translation, emphasis is ours).

The fear of the body-subject Mascarenhas (or Lima Barreto) is to become, with experimentation and the absence of medical method and logic, a body-object. Mascarenhas distrusts and fears the imprecise rules of psychiatry that allow the doctor, through experimentation, to make exceptions in them and act unethically in dealing with the patient.

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8.3.3 Legal Norms of the State Applied to the Afro-­Descendant, Immigrant, Indigent and Insane Body-Subject As already argued, the psychiatric hospital community is heterogeneous, made up of several marginalized segments. The criticism we make is that the State, through the police, arrests these subjects in the hospital for being exactly who they are. The police, I don’t know how or why, acquired a mania for generalizations, and the most childish ones. They are suspicious of every foreign subject with a twisted name, so the Russians, Poles, and Roma are necessarily pimps for her; every citizen of color must be a shark; and all madmen must necessarily be furious and transportable only in armored cars. Super-acute policemen should realize well that there are as many forms of madness as there are temperaments among more or less sane people, and the furious are the exception; there are even demented people who, perhaps, were better transported in a funeral coach and inside a coffin than in that unpalatable yoke made of iron and bars. (Lima Barreto 1993, p. 121, own translation, emphasis is ours).

The man, who is arrested in the psychiatric hospital and who corresponds to the character of Mascarenhas, wonders why he was arrested by the police if he did not commit any infraction, why, finally, the laws do not serve him, that is, why he is considered in principle outside the law. Also, why is he kept in an institution by a psychiatrist who classifies him as a lunatic? The terrible thing about this hospital thing is having to receive a doctor who is imposed on us and often is not one we trust. Furthermore, the doctor who is faced with a patient in police custody and the impersonality of the law, a curator, no matter how good he may be, no longer counts him as a person, he is a castaway, a husk of society, his unhappiness and misfortune can still be useful for the salvation of others, and his stubbornness in not wanting to provide this service appears in the doctor’s view, like the revolt of a prisoner, in the name of the Constitution, in full view of a police chief. Is the Constitution there for you? I have not seen any of this, but it is a general feeling that no one, not even the doctors themselves, will deny in good faith (Lima Barreto 1993, p.  174, own translation, emphasis is ours).

Both the state’s action in arresting him and the doctor’s action in keeping him imprisoned show us the absurdity of the situation of the institutionalized: because he was born insane, black, indigent and immigrant, legal and psychiatric norms dictate that they must be outlawed from society.

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8.4 An Interpretation of O Cemitério dos Vivos Based on Emmanuel Levinas 8.4.1 The Vulnerability of the Body Between Lucidity and Madness “Madness faintly manifests a man’s power”, stated Henry Maldiney (2018, p. 64, own translation), in one of his interviews. This is the ambiguity through which the body, forgetful of itself in the midst of so much suffering, and even being objectified and dominated by power structures, can paradoxically reappear as a powerful force in the struggle with the misfortunes and failures of existence. The human in us resists, making us unique in responsibility. Levinas’s phenomenology helps to think about these, so to speak, ethical implications of madness, especially those that we can find in Lima Barreto’s work O Cemitério dos Vivos. As much as Merleau-Ponty, Levinas attributes paramount importance to the body and to sensitivity in the understanding of the subject in its relations with itself, with the world and with others. We cannot explore in detail the different stages and formulations of the body problem in Levinasian phenomenology. We only affirm that bodily existence is a drama whose complexity is summarized in two inseparable movements: it is thanks to the body that the ‘I’ frees itself from the anonymity of being and its neutrality (from the absurdity that permeates the flow of being); at the same time, the body condition makes the subject a kind of opening to otherness, becoming meaning, that is, ethical responsibility as ‘one-for-the-other’. In the latter case, the struggle to get out of the non-meaning or absurdity of an impersonal existence (where nothing human and substantial is contained) takes place ethically in the relationship with the other based on sensitivity. In this regard, it is critical to understand the following. If we are touched by the other in spite of our will and decision, and if, for Levinas, the conception of an own body sensibly and responsibly oriented towards alterity is found there, even so, the non-meaning will always be lurking, threatening the ethical subject with madness and darkness. Everything happens as if the risk of madness always surrounded the ethical meaning (exposure to the other). This risk is the condition for the supposedly lucid and rational subject to maintain his vigilance against his own arrogance or desire for domination, a desire that makes him an accomplice, sometimes secret, of the current power systems. We speak, with Levinas, of being impersonal. The fundamental human experience of being is not one of understanding, as in Heidegger, but of being faced with a suffocating neutrality. The being simply does not answer us. The spectacle of what is to become cannot be contained or stopped. But the subject has to master it somehow. How? Detaching himself from it, affirming himself by a substantiation (hypostasis). “The being is absolutely foreign and shocks us. We suffer his suffocating grip like the night, but he doesn’t respond. He is the evil to be. If philosophy is the question of being – it is already the assumption of being”. (Levinas 2013a, p. 23, own translation).

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Why does this strange phenomenology contribute to a reflection on O Cemitério dos Vivos? The novel’s hero clearly manifests this feeling of limitlessness and formlessness that contrasts with every desire for understanding and every denial of the absurd. I was loathe to personalize with this or that name the unknown, the formless, the vague. Giving a nickname would limit the unlimited, define the indefinite, distinguish the indistinct, make the imperishable perishable (...). This being must have neither body, nor form, nor extension, nor motion, nor any other quality with which we know existing things (Lima Barreto 1993, p. 129, own translation).

The feeling of incomprehension and emptiness that Levinas talks about can emerge in us from a simple conversation. Mascarenhas hears from a young man confined to the asylum the narrative of his crime (a murder). The young man showed no ceremony or modesty. What does this event contribute to triggering in Mascarenhas? The dread and incomprehension of life. This is the hard feeling of someone who lives with so many souls marked by the loss of ‘reason’. This disturbance of the soul reveals the absurdity of being, its inhumanity, its ‘non-response’, its non-meaning. The order of being, which in tradition was understood from ideas such as harmony, teleology and goodness, breaks down, giving way to a nihilistic conception of the world and of life. The novel’s hero senses the mystery and the ‘no answer’ of being: It was in such a state of mind, penetrated by a profound intellectual nihilism, that I entered the asylum for the first time; and the gross painful spectacle of madness further ingrained in my spirit this conception of a misty world, almost plunged into darkness, being only perceptible suffering, pain, misery, and sadness involving everything, sadness that nothing can beat or reduce. (Lima Barreto 1993, p. 130, own translation).

Now, it is precisely when meaning is overflowed by non-meaning (in Levinasian terminology this is called Il y a, that is, the impersonal being, without any connotation of gift or generosity) that subjectivity is restless, persecuted or tormented by the relationship with the world and others awaken to their condition of responsibility. The ‘I’ discovers itself as pure sensitivity, exposed skin, vulnerability. It is exposed to the other, without any expectation of reciprocity, reward or self-fulfillment. In Levinas’s words: “In this overflow of meaning by non-sense, sensitivity – the Self – only accuses itself, in bottomless passivity, as a pure sensitive point, as dis-interest (...)” (Levinas 2013b, p. 255, own translation). The self, described phenomenologically by Levinas as pure passivity, nameless ipseity, without participation in the social and symbolic order of culture, is the human in its corporeality, which is also irreducibility to the system, to history, to nature, that is, it is the corporeal self being the non-synthesizable par excellence, which cannot be enveloped by a Totality. Without the subject as sensibility, alterity itself could not be produced in being. The corporeal self is the deepest intimacy in ourselves, the incommunicable making possible all communication, all openness to the domain of logos. We believe that Lima Barreto is, in this respect, very close to Levinas, because, in his memoirs disguised as a novel, he does not hesitate to refer to a background of passivity and vulnerability as the origin of everything in us that can be called human. Behold, it was not exactly the drink or the vice that made the

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hero a separate and excluded sensibility from the order of being, but the background of passivity that constitutes him. All the difficulties of life resulted from an intimate and deep suffering, that is, they are due to something unspeakable that lives in the innermost part of the Self, a kind of secret that will never be able to be communicated (Lima Barreto 1993, p. 144). This secret deep within ourselves, never completely overcome, is the condition for the human world of meaning (language, culture, social order, etc.) to be constituted. But it is also the possibility of describing one’s body as sensitivity, exposure to the other, making the subject an accused, even though he has not committed any fault. Why say that the bodily self is found in the accusative? Because sensitivity makes it a unique subjectivity, without recourse to an identification coming from logical and ontological, and even cultural, classifications. In the terminology of the philosopher Michel Serres, it is the ‘I’ not thought of from the ‘libido of belonging’, that is, the identity that comes from a culture, a language, a genealogy, and even a contractual obligation. Now, this identity libido “generated most of the crimes in history” (Serres 2004, p. 80, own translation). In O Cemitério dos Vivos, there are passages that clearly and literarily show the experiences of a subject who woke up to himself as expelled from identities conferred on him from abroad, that is, from identifications that come from his ‘libido of belonging’: I had forgotten myself, I had acquired a great contempt for public opinion, which disdains, which sees a person who passes through the asylum as a criminal; I had no more ambitions, no hopes of wealth or position. (Lima Barreto 1993, p. 145, own translation).

This expulsion of being, or even this awareness of oneself as being outside of the Totality (culture, history, society, politics, etc.), will have decisive consequences in the inter-human sphere. The subject feels destitute, naked, exposed, vulnerable. Everything seems to be swallowed up by the non-sense of an atmosphere charged with inhuman forces that dissolve the personality. It is at this moment that something of enormous significance occurs: the hero is dealing with madness in full lucidity. In this experience of the horror of the night (an expression dear to Levinas), Mascarenhas is sensitively affected, in his defenseless skin, by otherness; a condition that is a true event, like that of the memories of the loving and misunderstood wife. Memories that brought him bitter feelings of remorse. The image of the deceased woman affects him and fills him with regret, as she was in fact a patient, friendly and loving presence, always ready to teach authentic love, one that gives priority to the other, desiring their good without expectations of reward. The horror of madness does not dissolve the human sense. On the contrary, it is the former which makes the latter appear. But how? It is because the terrible thing about madness, by being the silence, ie. the silent attitudes and manias (Lima Barreto 1993, p. 147), make us look at humanity with pity. Madness, with all its horror, makes us think of O Cemitério dos Vivos, where indigents who feel they are dying passively await their own death (Lima Barreto 1993, p.  148). This is the encounter with ‘absolute darkness’ (Levinas’s Il y a), the painful feeling that madness brings. In madness, the ‘I’ discovers itself as ‘other’ in itself. Such a feeling makes us see, with lucidity, that we are insignificant and extremely fragile (Lima

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Barreto 1993, p. 145). In the midst of the sad illness, the body itself is forgotten, as well as the dignity of being human. The description is sharp: “I had lost all social protection, all right over my own body, I was just like an anatomy corpse in an amphitheater” (Lima Barreto 1993, p. 175). Curiously, what is experienced in the asylum is the impossibility of being alone, having to live with the other and others, maintaining dignity and compassion for the suffering of others. The caregivers of the sick, simple beings, without intellectual training, were living examples of renunciation and abnegation.3 They did not think they were better or worse than the sick. They lived in a kind of proximity and familiarity with so many tattered lives, they witnessed the human, without pride or vanity for the care given to so many souls alien to the supposedly normal life (Lima Barreto 1993, p. 164). Both the experience of the hero (a mask of Lima Barreto himself?) and that of those humble peasants who took care of the insane were the clearest and most moving expression of the face-to-face encounter of existing humans dealing with the joys and pains of the world. The hero who experiences the madness of the other, however, represents, in our perspective, the face of the other that, for Levinas, pursues and challenges consciousness. What is discovered in the end? That the sufferance, the deep pain of a failed existence, the horror of a reality that neither answers nor consoles us is not evil in a strong sense. But how? Because evil is not what we suffer, but what we are always capable of when we reproduce the injustice and violence of the world. Lima Barreto’s hero, who is no doubt the writer himself in the form of his fictional characters, discovers, thanks to fundamental and traumatizing events of his wasted life that the evil happens to him is not the true face of evil. It is the evil that we do, that comes out of us and emerges through our decisions and actions, which is the real face of suffering. In the evil (suffering) that follows me another evil involves me  – that suffered by the other human being. I am then involved and enjoined to go out of myself, to leave the comfort of my ‘good conscience’. The horror of the evil that I experience produces, precisely, horror at the evil suffered by the other human being. (Levinas 2002, p. 181–182). Lima Barreto, like Levinas, leads us to the paradox. The experience of madness takes place in complete lucidity. The relationship with the other in his fragility is always traumatic, uncomfortable and painful. It is pain that keeps us vigilant about ourselves and the atrocities of the world. It is the night of impersonal being, with its suffocating murmur and nonsense that keeps us close to meaning, to the human as awareness of responsibility. The I that experiences madness in complete lucidity notices its fragility, its impossibility of dominance, of being the one that commands and defines the meaning of the world and things. The ‘I’ discovers it is vulnerable, in an extreme passivity, which takes away all hope of having power over the world and life (Levinas 2013b, p. 255).

 Based on Merleau-Ponty, we made an opposite interpretation to that of the living body or bodysubject and the body-object subjected to the administration and doctors of the hospital. 3

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But this is the paradox: it is in this extreme vulnerability, or this feeling of fear at nature and life, that emerges a body itself capable of feeling, action and affirmation of the world and life. The opening to good is an elevation, states Levinas (2002, p. 182), as it engages us in a task without hope of reward or payment. Raising oneself to the Good is refusing evil and the suffering of the other, it is struggling so that our lives, even facing the pains of obscurity and the loss of meaning, can take on an aura of humanity and civility. The evil I suffer is not what counts most, after all. The suffering of others awakens meaning in me in the midst of total non-meaning. My thoughts were with the whole of humanity, in misery and suffering, with those who suffer, and all those who are cursed (...). I was filthy dirty, but I felt that, inside, I shone with goodness (...) (Lima Barreto 1993, p. 145, own translation).

In total poverty and suffering, feeling a failure and humiliated in the eyes of life and the world, humanity reveals itself in us, “the primitive nucleus of love and goodness”, that is, the human being, poor and naked, feels responsible for the whole of humanity, mainly for those who suffer, for the massacred and destitute. The poor and naked body, Levinas says, inverts the movement of the making of the world, questioning the privilege of consciousness in giving meaning to things. Before the world as representation of a subject of knowledge, above all others in its concepts and judgements, what we have is “the embodiment of the living being and the poverty of a naked and hungry body” (Levinas 1974, p. 103, own translation) bringing about a separation, that is, an ipseity capable of being wrenched from its structural egoism (and not necessarily moral), becoming sensitive consciousness, responsible for the other human being. Thus, the vulnerability of the body, with all the risk of madness that it contains, manifests paradoxically ‘man’s power’. We have, then, a bodily self shining goodness and love for others, struggling so that others are happier than us. In this way, in the guise of the hero of his novel, Lima Barreto, in the midst of the crisis of meaning that overwhelmed and destroyed him, “sought out and sounded out the mysteries of our moral nature, (with) the desire to discover in our defects his primitive nucleus of love and goodness” (Lima Barreto 1993, p. 145, own translation).

8.5 Conclusion If Merleau-Ponty and Levinas had had the opportunity to read Lima Barreto, we think they would have reached the same remarkable conclusion about sensitivity: body (living body in Merleau-Ponty and body - corps - in Levinas), being vulnerable and exposed to suffering and pain, can find, in full experience of madness, the meaning of the human as responsibility and solidarity. They would propose that the condition of subject is not that of being an accomplice of power structures, it is not that of being at the service of a system. O Cemitério dos Vivos allows access, in a poetic-literary way, to the core of subjectivity, an access that, in its own way, the phenomenology of ipseity tries to describe. Subjectivity that is understood unlinked

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from forms of identification originating from a culture, a language or a tradition. Subjectivity outside being, Levinas would say. The human in us is not a fixed essence, not even the ‘having to be’ for which, above all, finitude itself, anguish in the face of death, matters. It is all bodily life that is guided and held accountable by the other, as well as exposed to the non-meaning risks that this responsibility implies. Levinas takes responsibility for the ultimate consequences, saying that the ‘I’ is hostage to the other. Merleau-Ponty does not go that far. Perhaps, for this very reason, his phenomenology benefits from situations that Levinas’s analyses leave open. For example, the world of art is a space of affection, relationships of meaning and construction, in which sensitive subjectivities will be open to the possibilities of overcoming oppression, domination and domestication. The body is power in fragility. It proposes new instituting possibilities, new forms of communication, in a word, that launches us into the challenge of an active solidarity in the world. Both, however, do not give up a situation that, as the great Lima Barreto taught, puts human beings one against the other, stripped of all forms of logical-ontological, social and cultural identification. It is then that, even in situations that seem to clearly manifest the downfall of the human, the ‘I’ awakens, realizing the “kindness and sympathy of man to man, regardless of interest and kinship” (Lima Barreto 1993, 151–152, own translation).

References Barbosa-Fohrmann, Ana Paula. (forthcoming). Narrating Experiences of Alzheimer’s through the Arts: Phenomenological and Existentialist Descriptions of the Living Body. Levinas, Emmanuel. 1974. Totalité et Infini. La Haye: Martinus Nijhoff. ———. 2002. De Deus que vem à ideia. Petrópolis: Vozes. ———. 2013a. De l’existence à l’existant. Paris: Vrin. ———. 2013b. Autrement qu’être ou au-delà de l’essence. Paris: Le Livre de Poche. Lima Barreto, Afonso Henriques de. 1993. Diário do Hospício; O Cemitério dos Vivos. Rio de Janeiro: Secretaria Municipal de Cultura, Departamento Geral de Documentação e Informação Cultural, Divisão de Editoração. Maldiney, Henri. 2018. O filósofo que tenta compreender a loucura. In Fenomenologia e Arte. Maldiney no Brasil, Nelson Aguillar. São Paulo: EDIUSP. Merleau-Ponty, Maurice. 1964a. Cézanne’s Doubt. In In sense and non-sense, Maurice Merleau-­ Ponty, 9–25. Trans. Hubert L.  Dreyfus and Patricia Allen Dreyfus. Evanston: Northwestern University Press. ———. 1964b. L’oeil et l’ esprit. Paris: Éditions Gallimard. ———. 1969. The visible and the invisible. Trans. Alphonso Lingis. Evanston: Northwestern University Press. ———. 2002. Phenomenology of perception. Routledge Classics: Trans. Colin Smith. New York. Proust, Marcel. 2016. Em Busca do Tempo Perdido: No Caminho de Swann. Vol. 1, Trans. Mario Quintana. São Paulo: Biblioteca Azul. ———. 2005. Swann’s way: Webster’s German Thesaurus Edition. San Diego: Icon Classics. Serres, Michel. 2004. Ramos. Instituto Piaget: Lisboa.

Chapter 9

The Rights of Children with Psychosocial Disabilities and the Prescription of Antipsychotics in Childhood Sandra Caponi

Abstract  The objective of this chapter is to initiate a discussion in the field of the human rights of people with psychosocial disabilities, challenging the prevailing hegemonic medical model. I propose to examine the arguments used to legitimize and spread the use of antipsychotics, with serious side effects and questionable benefits, for children who suffer from some type of psychosocial disability. I argue that the effective guarantee of “respect for the developing capacities of children with disabilities” is called into question when the use of antipsychotics in childhood is trivialized. In this chapter, I particularly discuss the prescription of atypical antipsychotics for undisciplined and disobedient children. Keywords  Antipsychotics · Children · Drug-centred model · Human rights · Psychosocial disabilities · Iatrogenic harm · Adverse effects

9.1 Introduction Time and again, we read in newspapers and scientific publications of a considerable increase in mental disorders in the population, both adults and children, as a result of their experiences during the Covid-19 pandemic. Much is said about the increase in depression, anxiety, post-traumatic stress disorder, and eating disorders that have

This book chapter was accomplished within the framework of the Capes-Cofecub international agreement between the Federal University of Santa Catarina and the University of Paris 8/ Vincennes- Saint Denis. Capes-Cofecub Project: Capes process number. 88881.191755/2018–01/ Cofecub process number Sh 940/19. S. Caponi (*) Department of Sociology and Political Science, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Brazilian National Council for Scientific and Technological Development, Brasília, Brazil © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_9

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increased greatly as a result of the pandemic. The newspaper El Pais speaks of a ‘Tsunami’ of cases registered in Madrid, which has led to a list of more than 10 teenagers awaiting admission to the Acute Patient Unit of the Gregorio Marañon Hospital, where 90% of hospitalized patients are female adolescents (Menárguez 2022). The pandemic seems to have multiplied psychological suffering, particularly in children and adolescents who have lost their social networks and sense of belonging. As an undesired consequence, we witness the proliferation of psychiatric diagnoses, which are limited to counting symptoms established by the provisions of the Diagnostic and Statistical Manuals of Mental Disorders (DSM-5) (APA 2013). These diagnoses are often unnecessary and mask personal distress and social issues arising from the pandemic. Now seems to be a propitious moment to reflect on the limits and scope of the dominant medical model in the field of psychosocial impairments in general, and in childhood in particular. Let us remember that the Convention on the Rights of Persons with Disabilities (UN 2006) aims to guarantee the protection and ensure the exercise of human rights, guaranteeing the fundamental freedoms of all people with disabilities, including those with psychosocial disabilities. Brazil was a direct participant in the development of this Convention, assuming the international commitment to respect the established principles: Respect for inherent dignity, the independence of the person, including the freedom to make one’s own choices, individual autonomy, non-discrimination, full and effective participation and inclusion in society, respect for difference, equality of opportunity, accessibility, equality between men and women and respect for the developing abilities of children with disabilities. (UN- Brazil 2007).

Act No. 13146, known as the Brazilian Law for the Inclusion of Persons with Disabilities (LBI), dated July 6, 2015, defines, in article 2, the group of people to whom the law is addressed in the following terms: A person with a disability is considered to be one who has a long-term impairment of a physical, mental, intellectual or sensory nature, which, together with one or more barriers, may impede his or her full and effective participation in society on an equal basis with other people (Brazil 2015).

I will analyse here mental or psychosocial disability in particular. According to Guillen (2018), the World Health Organization (WHO) defines psychosocial disability as: “people diagnosed with a mental disorder who have suffered the effects of negative social factors such as stigma, discrimination and exclusion”. Sassaki (2011), on the other hand, speaks of psychosocial disability as synonymous with ‘psychiatric disability’ or ‘mental health disability’, including common mental disorders such as mania, schizophrenia, depression, obsessive compulsive disorder or paranoia (Sassaki 2011). The first issue that we can observe in these references is that psychosocial disability continues to have a biomedical reference as its starting point. There is talk of diagnoses and psychiatric disorders, although not limited to the mere mention of diagnoses but integrating the social facts that produce situations of stigma, exclusion and prejudice.

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The Brazilian Law of Inclusion, insofar as it covers people with psychosocial disabilities, guarantees that all people who suffer from a mental disorder or who suffer from the sequelae of a psychiatric disorder are guaranteed all their rights, and that their access to public policies, active social participation, work, leisure, study and also health is safeguarded, as defined by the Convention on the Rights of Persons with Disabilities. In addition to adults diagnosed with the aforementioned disorders, the Law ought to guarantee the protection and inclusion of children and adolescents who have some type of global developmental disorder. Sassaki mentions some of these disorders: Asperger Syndrome, Rett Syndrome, psychosis and autism. Today, we must extend the benefit of the Law (LBI) to all children diagnosed with psychiatric pathologies such as childhood depression, bipolarity, Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiance Disorder (ODD), Autism Spectrum Disorder and other psychosocial disabilities in childhood. I believe, on the contrary, that it is necessary to think about psychosocial deficiencies from the point of view of the rights to be secured and the limitations that society imposes on people with psychological ailments or suffering rather than from a model focused on diagnoses. In addition to the social contexts that perpetuate stigma and prejudice, we must also question the impact of psychopharmacological diagnoses and therapies. Considering the social inclusion of children and adolescents who suffer from some type of developmental, mood or behavioural disorder within the framework of LBI, we need to be aware of the possible damage caused by psychopharmacological therapies that can affect the individual’s life, their development and their health. In order to achieve the objective of guaranteeing the rights of people with psychosocial disabilities, we should be aware of the historical experiences of groups of psychiatric patients and ex-patients who, for more than 50 years, have been sharply critical of psychiatric power. Such criticism refers not only to abuses perpetrated within psychiatric hospitals, but also to the prescription of psychotropic drugs whose effects can be debilitating, with profound and potentially irreversible consequences. Fernandez (2010) highlights marginalization, exclusion and stigmatization as the most serious problems faced by people with psychosocial disabilities, from the isolation imposed in psychiatric asylums to restrictions on autonomy and violent treatment in the form of shock therapy. During the last decades of the twentieth century, criticism of the stigmas suffered by the so-called mad, demented or incapable multiplied, and various forms of resistance to medical-psychiatric power emerged. Sassaki refers to the self-help groups of the 1960s and the experiences of survivors of 1980s psychiatry (Sassaki 2011). Peer support groups of so-called psychiatry survivors remain active to this day. Other groups, such as Voice Hearers or the collectives of experts by experience (Rose 2019), are politically committed to the task of showing the limits of biological psychiatry in relation to reducing profound psychic ailments and in the use of poorly understood psychiatric categories as well as

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to giving visibility to the adverse effects of certain treatments, such as electric shock therapy or the prescription of potent psychotropic drugs. These groups of psychiatric patients denounce the extent to which the prescription of medication, particularly antipsychotic drugs, for continuous use or for long periods has been harmful to their lives. It is already known that when antipsychotics or other psychotropic drugs, such as Ritalin, are prescribed at preschool age (Whitaker 2022), in childhood or adolescence, the results can be very harmful to the physical, emotional and mental development of children. The objective of this chapter is to initiate a discussion in the field of the human rights of people with psychosocial disabilities, challenging the prevailing hegemonic medical model. I propose to examine the arguments used to legitimize and spread the use of antipsychotics, with serious side effects and questionable benefits, for children who suffer from some type of psychosocial disability. The effective guarantee of ‘respect for the developing capacities of children with disabilities’ is called into question when the use of antipsychotics in childhood is trivialized.

9.2 The Disease-Centred Model and Psychopharmacological Therapy When we think about the subject of mental health from the point of view of human rights and the Convention on the Rights of Persons with Disabilities, we are implicitly taking as a starting point a social model of psychosocial disability. This model should replace the classic approaches of legal protection for the disabled, and the reductionist medical model focused on disease and cure (Sabin Paz, Sobredo 2013; Diniz 2017; Barbosa-Fohrmann and Vivas-Tesón 2020). However, in order to transcend these outdated models, prevailing despite advances in legislation, it is necessary to dismantle the mechanisms on which this discourse is constructed, that directly associate psychosocial disability with mental illness and that reduce the right to access therapy, usually psychopharmacological. I propose to analyse the process by which the prescription of psychiatric drugs became widespread and naturalized to such a point that, for many people with deep psychological suffering, access to psychopharmacological treatment seems to be their only justifiable right. This reinforces a reductionist and stigmatizing model that strengthens exclusions and fails to acknowledge that psychosocial deficiencies can be “a consequence of contemporary social organization that has little regard for people with some type of disability in the functionality of their body and mind” (Sabin Paz, Sobredo 2013). In order to understand the persistence of this medical approach to psychosocial deficiencies, more particularly to question the legitimacy of the arguments referring to the effectiveness of treatments with psychotropic drugs, I analyse two explanatory models of the action of psychiatric drugs identified by the critical psychiatrist

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Joanna Moncrieff. These two models of action of psychotropic drugs are: the disease-­centred model and the drug-centred model. The first model has as its starting point the identification of psychiatry with general medicine, assuming the existence of a biological disease, an organic alteration that might be completely reversed by drugs or limited by eliminating the constellation of symptoms that define it. According to this model, psychotropic drugs would act in an identical form to other drugs, whose function is to reverse the organic causes of the disease, as with antibiotics, or to control the symptoms of an organic alteration, as occurs with analgesics. An example that psychiatrists often reference in an effort to reinforce the disease-­ centred model is the use of insulin for diabetes. By addressing the physiological difficulty in producing the hormone insulin, replacement insulin therapy helps restore the body to its normal state. On the other hand, symptomatic treatments, such as analgesics, also act by focusing on the disease since their effect is to neutralize some of the physiological processes that produce pain. (Moncrieff 2008, 2013). According to this model, psychotropic drugs act by balancing a diseased or abnormal nervous system. Thus, the desired effects of psychotropic drugs are those that reverse the disease process and its manifest symptoms. Secondary, collateral and unwanted effects are considered to be the effects produced by the drug that are not directly linked to the disappearance of symptoms, for example, psychomotor slowness, mental confusion, insomnia, increased appetite and weight gain, among others. However, the epistemological foundations of this disease-centred explanatory model are extremely weak. This is because there are no reliable scientific studies that allow us to understand the neurochemical or genetic causes of psychiatric illnesses. We do not know the causal networks that would explain which brain changes or neurochemical imbalances constitute the etiology of psychiatric pathologies. There are no laboratory studies with animal models that can be considered conclusive, there are no brain scans or comparative studies that indicate a difference between the dopamine level of a subject diagnosed with schizophrenia and a healthy subject. Moncrieff contrasts this model, which classically defines the use of drugs in different areas of general medicine, with another approach, which he calls the ‘drug-­ centred model’. It is a model that applies exclusively to psychotropic drugs, as it cannot be applied to drugs used in other fields of medicine. According to this model, psychiatric drugs, far from correcting an abnormal state or restoring a lost neurochemical balance, function by inducing changes in the brain, producing an abnormal or altered state. For Moncrieff, psychiatric drugs have a mode of action based on cerebral intoxication, in the same way that other psychoactive substances such as alcohol, heroin, opium or other recreational drugs act. This is what happens, for example, with stimulants like Ritalin. The disease-­ centred model claims that methylphenidate can restore a neurochemical balance, which is the hypothetical cause of Attention Deficit Hyperactivity Disorder.

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However, it is possible to observe that this drug works in the same way and has the same effects, both in children and adolescents diagnosed with ADHD, as in those who do not have a psychiatric diagnosis and simply want to boost their concentration, for example, before an exam. Psychotropic drugs are psychoactive substances that act by modifying brain functioning, producing behavioural, intellectual and emotional changes. Each of these psychoactive substances will have a different effect, in the same way that the effects caused by the consumption of different recreational drugs, such as alcohol, cocaine or marijuana, are not identical. Some effects will be considered beneficial for people who consume these drugs, helping them to relax, to concentrate, or to feel more active and stimulated. For many, these beneficial effects outweigh the negative or side effects these drugs produce. For this reason, Joanna Moncrieff argues that, if we align ourselves with the drug-centred model, we can say that the psychoactive effects produced by some drugs can be therapeutically useful in certain situations. What Moncrieff proposes with this apparently simple distinction is nothing more than an invitation to “speak clearly”, to recognize that this is what actually happens in the field of psychopharmacology. The disease-centred model, which is hegemonic in biological psychiatry, seems to have failed because, to date, it has not been possible to identify the etiology of psychoses or other psychiatric disorders. Even so, defenders and propagators of the disease-centred model insist on affirming that psychotropic drugs are efficient in treating mental pathologies, in restoring lost normality or in rebalancing neurochemical alterations. On the contrary, in daring to talk about psychiatric drugs from a drug-centred perspective and to address the effect they have on users, means recognizing that the prescription of psychotropic drugs is based more on the effects provoked than on their ability to reverse a pathological state. In other words, this means affirming that psychotropic drugs are closer to drugs for social or recreational consumption, such as alcohol, than to drugs such as insulin, penicillin or aspirin. In the specific case of antipsychotics, it is affirmed that they block neurotransmitter receptors such as dopamine. Authors such as Moncrieff (2008), Gøtzsche (2015), Nikolas Rose (2019) or Whitaker (2010), argue that ‘the neurochemical deficit theory, which is the most widespread theory about the origins of psychiatric symptoms and disorders, has, in fact, little scientific basis as a foundation’. This may disregard the action of neuroleptics as being inextricably linked with apathy, emotional neutrality and the reduction of mental capacities, insofar as they “act like a straitjacket with effects on conduct and mental processes” producing something akin to a ‘both physical and mental deactivation’ (Breggin 1991). Considering the effects caused by antipsychotics, I propose to analyse the dissemination of the supposed therapeutic efficacy of neuroleptics in the field of childhood, particularly when we analyse the prescription of atypical antipsychotics for supposed psychiatric illnesses linked to unwanted childhood behaviours. Understanding the effects that antipsychotics cause in childhood can help us to think about the existing problems in the disease-centred model of psychosocial disability and the urgent need to replace it with a social model of disability. Such a

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model would be capable of questioning the violation of human rights that occurs when medications that produce severe sequelae are prescribed, without patients being properly informed of the adverse effects of the medication and without there being a policy that requires informed consent from patients before these powerful psychotropic drugs are prescribed.

9.3 Antipsychotics for Unruly Children As Pignarre (2006) states, all the effort that the pharmaceutical industry has devoted over the last 50 years to psychotropic drugs in general and to antipsychotics in particular, seems to be reduced to finding a drug with fewer side effects than the existing drug in the market. However, this does not equate to them being therapeutically more effective or less harmful than the antipsychotics discovered in the 1950s (Deniker 1987), such as chlorpromazine. When we consider the antipsychotics licensed by ANVISA, the National Health Surveillance Agency, for pediatric use in Brazil, we see that there is authorization for two typical or first-generation antipsychotics, Chlorpromazine and Haloperidol, and two atypical or second-generation antipsychotics: Risperidone and Quetiapine. To our surprise, and despite all that is already known about chlorpromazine, the adverse effects of the drug having been publicized for more than 70 years, chlorpromazine, particularly the brand Amplictil, from Laboratório Sanofi, is recommended for pediatric use from 2 years of age. Today, as when chlorpromazine was discovered in 1956 (Delay and Deniker 1956), we know the side effects: (1) akathisia, that is, movement disorders and psychomotor agitation; (2) dystonia, that is, involuntary movements and muscle contractions; and (3) tardive dyskinesia, that is, symptoms similar to Parkinson’s disease. In the patient information leaflet for Amplictil we read, Use in children (from 2 years old) should use the same treatment regimen already recommended, with a gradual increase in the dose, an initial dose of 1 mg/kg/day, divided into 2 or 3 doses being most common. The total daily dose should not exceed 40 mg in children under 5 years of age, or 75 mg in children over 5 years of age. (ANVISA 2018).

The same 40 mg that Delay and Deniker, the developers of chlorpromazine, recommended in 1956 as the maximum dose for psychotic adult patients admitted to nursing homes, is now recommended for children aged 2–5  years. Although classic antipsychotics are rarely used in children and adolescents, this is not the case with atypical antipsychotics such as risperidone, whose trademark is Risperidal, from the Janssen laboratory. Risperidone is widely used as a pediatric medication in Brazil and in countries around the world. This drug is indicated for children with autism, agitation, hyperactivity and also for children and adolescents who are diagnosed with Oppositional Defiant Disorder - ODD. The latter is an extremely ambiguous disorder, which actually refers to a set of socially undesirable behaviours, such as the non-acceptance of

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authority figures, hostile or defiant behaviour. These behaviours, although potentially inconvenient and stressful, are not symptoms of any psychiatric pathology. Throughout the 1980s, there was increasing criticism and studies that showed the low effectiveness of classic antipsychotics, such as chlorpromazine, for the cure or better control of the symptoms of psychiatric disorders such as schizophrenia. In this context, antipsychotics with fewer side effects than the previous ones appeared as a promising alternative to the problems presented by classic drugs. Thus, according to Whitaker, throughout the 1980s, Researchers began to admit that neuroleptics did not control hallucinations very well. Two-­ thirds of all medicated patients had persistent psychotic symptoms one year after the first psychotic break. Thirty percent of patients do not respond to the drugs — a “non-response” rate that, until the 1980s, had almost never been mentioned. Several studies suggest that this 30% figure could be very low, and that up to two-thirds of all psychotic patients could be considered “non-responders” to neuroleptics. Possibly the most revealing confession of all came from the NIMH scientists: “Our clinical experience is that while the intensity of the thought disorder may decrease with drug treatment, the thought disorder is not changed” (Whitaker 2002, p. 480).

The serious side effects caused by neuroleptics were increasingly publicized. Initially, the immediate solution of the pharmaceutical industry was to produce new drugs to control the adverse effects of neuroleptics, Cogentil, for example, is a drug used until today, which is presented as the solution to control the three extrapyramidal symptoms of Thorazine: akathisia, dystonia and akinesia. Later, the answer to the problems presented by neuroleptics seemed to come in the form of atypical antipsychotics. Psychiatry claimed that “earlier drugs were beneficial but problematic; the new drugs represent an advance over the previous ones”. Among the atypical antipsychotics, Risperidone was a huge commercial success, presented as a potent new antipsychotic, but without the unwanted effects of classic antipsychotics. Risperidone is a product from the Janssen laboratory, soon acquired by the Johnson & Johnson laboratory. It was discovered in Belgium in the late 1980s by Paul Janssen and colleagues. In 1986, the drug was presented to the FDA, being approved for consumption in the USA in 1993. Initially this drug was intended for the treatment of schizophrenia and psychosis, a little later, in 2007, the drug was authorized for use in adolescents. However, Risperdal was already widely marketed and prescribed to children and adolescents before it was approved by the FDA. In 1989, after two years on the market, risperidone was already accounting for 1/5 of antipsychotic prescriptions in the United States, a trend that continued to grow (Whitaker 2002). This drug was advertised and prescribed initially for the treatment of psychotic problems, later for Autism Spectrum Disorders and finally for so-called common childhood disorders such as Attention Deficit Hyperactivity Disorder; Oppositional Defiant Disorder; Obsessive-compulsive disorder. In Brazil, risperidone was authorized for use in children in 2014, initially for children with autism. It later became widely prescribed for adolescents diagnosed with Oppositional Defiance Disorders (ODD).

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The latter is a diagnosis given to increasingly younger children. Sometimes it appears as a single diagnosis and sometimes as a comorbidity associated with autism or Attention Deficit Hyperactivity Disorder (ADHD). What is certain is that, with the increase in cases encompassed by the broad range of Autism Spectrum Disorder, today Risperidone is prescribed to children aged two years and even younger, regardless of the fact that, as the patient information leaflet confirms: “There are no studies on the use of risperidone in children under 13 years of age”. (ANVISA 2018). Risperidone is also used as an adjunct to treatment for children diagnosed with ADHD.  We have witnessed a dramatic rise in the number of children diagnosed with ADHD (Attention Deficit Hyperactivity Disorder) both in Brazil and worldwide in the last 20 years. Ritalin, a widely used drug for this diagnosis, contains the active ingredient methylphenidate. A study carried out in 2017, based on the analysis of medical records of children and adolescents from a mental health service in São Paulo, called Childhood in the Hot Seat: About diagnostic labelling and the banalization of psychotropic prescription, the authors, Luana Vizotto and Danielle Ferraza (2017), show that there are several cases in which children received two associated drugs, Risperidone and Ritalin, even though 20% of them had no definite diagnosis. The use of medication in the absence of a diagnosis as a reference does not seem strange when we think from the perspective of a drug-centred model and consider that Risperidone is a potent sedative, a major tranquilizer. On the contrary, the patient information leaflet states, following the model of explanation centred on the disease, that it is a drug intended for the treatment of various mental disorders such as schizophrenia, psychosis, bipolar disorder. It is also indicated for the treatment of Alzheimer’s Disease in the elderly, the leaflet states that it is effective for the treatment of agitated, restless and autistic children: It can be used for the treatment of irritability associated with autistic disorder in children and adolescents, for symptoms ranging from aggression to others, deliberate self-harm, anger and distress crisis, and rapid mood swings. (ANVISA 2018).

This potent drug is also widely used for the treatment of crack and cocaine addicts (Rodrigues 2014). It is not surprising that the same drug can be used at the same time to treat Alzheimer’s, children with autism, drug addicts, people with bipolar disorder, mania, schizophrenia and also children who oppose and defy authority. In this context, it may be interesting to look away from the definition of an ambiguous diagnosis such as oppositional disorder (ODD) and ask ourselves why an aggressive child, with irritable behaviour, with a crisis of anger and rage, characteristics that cannot be identified with any pathology, receives a powerful antipsychotic like Risperidone, a sedative with serious side effects? It is clear that the medical literature will not refer to behaviour control, but to therapeutic effect. It does not maker reference to aggressive children, but to boys with a disorder. In other words, the efficacy of Risperidone is not considered in terms of the drug-centred model, but as a drug capable of curing a disease, thus hiding its powerful tranquilizing action. That is, a powerful drug, an antipsychotic, is

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used, with the argument that it is the recommended treatment for a non-existent pathology, even though the price that treated children must pay for the adverse effects is enormous. The manufacturers Janssen were aware that the drug presented serious health risks to children, as stated in the 2003 report referring to Risperidone for pediatric use: “its safety and efficacy in children has not been demonstrated” (Janssen 2003). Side effects identified by the laboratory include a milder expression of tardive dyskinesia than classic antipsychotics, adverse cardiovascular effects, hypoglycaemia and diabetes, seizures and hyperprolactinemia, among other symptoms, such as a change in skin colour (jaundice). In contrast, as Christopher Lane states, several recent studies show that Risperidone, like other antipsychotics, should be avoided in the pediatric field because they increase the risk of death in children and young people between the ages of 5 and 20 (Lane 2018). Regardless of this knowledge and repeated warnings from the FDA, the company continued to market the drug to children and teens. In response to a series of legal claims, Johnson & Johnson was required to pay US$2 billion in fines (Abrasme 2015). This is an insignificant amount if we consider that the company made a profit of almost US$ 30,000 million, in the same period, from sales of the drug. This drug can cause strokes in the elderly. It can result in the development of breasts in children; one boy developed a 46DD bust. However, Johnson & Johnson aggressively marketed Risperdal to the elderly and children, while allegedly controlling and withholding data on breast development. J&J was caught, pleaded guilty to a felony and paid over $2 billion in fines and settlements. But that pales into insignificance in the context of Risperdal’s almost $30 billion in sales worldwide. In short, crime pays if you’re a big corporation. (Kristof 2015).

9.4 In Conclusion: The Social Model of Psychosocial Disability Several authors (Sabin Paz, Sobredo 2013; Diniz 2017; Barbosa-Fohrmann and Vivas-Tesón 2020; Fernandez 2010) have highlighted the need to replace the medical model with the social model of disabilities in order to facilitate the necessary changes to guarantee the rights of people with disabilities. It requires awareness of barriers of different types - material, structural, educational, occupational - as well as situations of stigma, bullying, harassment and prejudice. Each of these situations needs to be analysed seriously so that, finally, we can guarantee “respect for individual autonomy, including the freedom to make their own decisions” (Fernandez 2010, p.14) for all people with some type of disability. It is my understanding that when we consider psychosocial disability, there is a need to go one step further. In this case, the transition from the medical model to the social model requires that we take seriously the problems created by psychiatric knowledge, by the proliferation of diagnoses and by the application of highly

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harmful therapies. For it to be truly possible to speak of a social approach in the field of mental health, we must begin a radical critique of the existing hegemonic model. This critique must be conducted with a focus on three aspects. (1) An epistemological analysis that enables us to demonstrate that the underlying certainties and evidence employed in psychiatry to establish diagnoses and define psychopharmacological therapies are epistemologically fragile and unsustainable. In other words, it is not possible to continue insisting on supposed neurochemical imbalances that would be corrected with drugs. (2) A critique based on ethics, since people with disabilities are not properly informed of the unwanted effects of drugs on their bodies, which suggests the need for mechanisms to guarantee clear, informed consent from patients, with experts who explain that antidepressants, used for long periods, produce chemical dependence and that withdrawal symptoms occur when they are discontinued; that antipsychotics produce severe extrapyramidal effects, such as Parkinson’s syndrome; that atypical antipsychotics, such as Risperidone, produce hyperprolactinemia, that is, the development of breasts and milk in male children and adolescents, among other side effects. (3) Finally, a social critique, centred on human rights, that allows us to listen to the voices of users of mental health systems. We must be heedful of repeated complaints made about the violation of rights that occurs with forced institutionalization; of the effects that shock therapies have on the body, memory and vital forces; and also of the repeated grievances about the unwanted effects that psychiatric drugs produce. In several situations, psychiatric drugs have a tranquilizing action, which leads to drowsiness, imposing calm and silent acceptance. In many cases, psychopharmacological therapy masks the adverse contexts and aggressions that caused the suffering, for example, domestic violence, psychological or sexual harassment, racism, and bullying, which remain unchanged when psychiatric medication is prescribed as the only solution. It is necessary to recognize that the proliferation of psychiatric diagnoses (APA 2013) and the trivialization of psychopharmacological therapies “generate psychosocial deficiencies insofar as they limit the development of daily activities such as studying, waking up to go to work, taking care of children, etc.” (Couttolenc 2010). When the medical model of psychosocial disability is applied to the domain of childhood, and it is limited to ever-increasing diagnoses and the prescription psychotropic drugs, the social barriers that children face in their daily lives might be overlooked. Consideration of the social model of psychosocial disability, for the creation of more inclusive and supportive societies, requires that we pay attention to what people who suffer from disabilities – experts through experience – have to tell us about their resistance strategies, their demands and their grievances. Nikolas Rose asks: But what about the voices of those who are the subject-objects of psychiatry: patients, users of mental health services, survivors of compulsory confinement, involuntary treatment, or long-term medication? Shouldn’t it be the people who should judge the benefits of psychiatry? (Rose 2019, p. 150).

We must integrate the voice of experts through experience, of survivors of psychiatry, of peer groups such as voice hearers, in order to fully understand how we must

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proceed in order to guarantee the existence of a social model of psychosocial disabilities that takes into account the requirements established by the International Convention. Health systems user, Cecilia Guillen, argues that the critical starting point to guarantee rights is to recognize the social spaces that stigmatize people with psychosocial disabilities, thus producing a series of exclusions, discrimination and avoidable suffering (Guillen 2018). The use of psychiatric drugs can reinforce these situations of stigma and prejudice and seriously limit the human rights of people with some type of psychosocial disability. As we know, psychiatric interventions have been characterised, throughout their history, by disregard for and violation of the human rights of many patients, both inside and outside psychiatric hospitals: either by the application of isolation measures, by the use of mechanical and chemical restraints, or by the use of harmful therapies such as electroshock or lobotomy. We must bear in mind this history of abuses in psychiatry in order to question the illegitimate claims of a medical model that addresses psychosocial deficiencies from the definition of diagnoses and the prescription of psychotropic drugs with direct effects on the development and health of children and adolescents.

References Abrasme Notícia. 2015. Mais de mil meninos tiveram seus seios crescidos, causa provável a risperidona. ABRASME, February 02, 1–2. ANVISA. 2018. Bula Amplictil. Anvisa.. http://www.saudedireta.com.br/catinc/drugs/bulas/ amplictil.pdf. Accessed 10 April 2022. APA. 2013. Diagnostic and statistical manual of mental disorders. 5th ed (DSM-5). Arlington: American Psychiatric Association. Barbosa-Fohrmann, Ana Paula, and Inmaculada Vivas-Tesón, eds. 2020. Cruzando Fronteiras: Perspectivas transnacionais e interdisciplinares dos estudos de deficiência. Porto Alegre: Ed. FI. Brasil. Lei n° 13.146, de 6 de julho de 2015 (Estatuto da Pessoa com Deficiência). 2015. http:// www.planalto.gov.br/ccivil_03/_ato2015-­2018/2015/lei/l13146.htm. Accessed 30 March 2022. Breggin, Peter. 1991. Toxic psychiatry. New York: St. Martin’s Press. Couttolenc, Myriam. 2010. Discapacidad psicosocial: “invisible” em México. México: Defensor Revista de derechos humanos. https://www.corteidh.or.cr/tablas/r25716.pdf. Accessed 4 April 2022. Deniker, Pierre. 1987. Psychopharmacologie. Ellipses: Les médicaments et drogues psychotropes. Paris. Diniz, Débora. 2017. O que é deficiência. São Paulo: Ed. Brasiliense. Fernandez, Maria Teresa. 2010. La discapacidad mental o psicosocial y la Convención sobre los derechos de las personas com discapacidad. México: Defensor Revista de derechos humanos. https://www.corteidh.or.cr/tablas/r25716.pdf. Accessed 1 April 2022. Gøtzsche, Peter C. 2015. Deadly psychiatry and organised denial. People's Press. Guillen, Cecilia. 2018. Personas con discapacidad psicosocial: invisibles, pero discriminadas. https://documenta.org.mx/blog-­documenta/2018/08/08/personas-­con-­discapacidad-­ psicosocial-­invisibles-­pero-­discriminadas/. Accessed 20 April 2022. Janssen. 2003. Risperdal Products L.P: Janssen. https://www.janssen.com/us/our-­products. Accessed 5 May 2022.

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Kristof, Nicholas. 2015. When crime pays: J & J ‘s drug Risperdal. New York Times. September 17, 1–3. Lane, Christopher. 2018. Antipsychotics tied to higher risk of death in children. Psychology Today. December 28. https://www.psychologytoday.com/us/blog/side-­effects/201812/antipsychotics-­ tied-­h igher-­r isk-­d eath-­i n-­c hildren#:~:text=The%20latest%20study%20demands%20 a,guidelines%20need%20adjusting%2C%20and%20soon. Accessed 5 May 2022. Menárguez, Ana. 2022. Auge de adolescentes ingressados em psiquiatria. El Pais, Saúde Mental. February. https://elpais.com/sociedad/2022-­02-­10/auge-­de-­adolescentes-­ingresados-­en-­ psiquiatria-­mi-­hija-­empezo-­a-­eliminar-­alimentos-­y-­entro-­en-­estado-­de-­hibernacion-­era-­ como-­una-­sombra.html. Accessed 10 May 2022. Moncrieff, Joanna. 2008. The myth of the chemical cure. London: Palgrave Macmillan. ———. 2013. Magic bullets for mental disorders: The emergence of the concept of na “antipsychotic” drug. Journal of the History of the Neurosciences 22 (1): 30–46. ONU-Brasil. Protocolo Facultativo-Convenção sobre os Direitos das Pessoas com deficiência. 2007. https://www2.senado.leg.br/bdsf/bitstream/handle/id/99423/Protocolo_facultativo_ Convencao_direito_pessoas_deficiencia_2008.pdf?sequence=4. Accessed 30 April 2022. Pignarre, Phyllipe. 2006. Les malheurs des psys: psychotropes et médicalisation du social. Paris: La Découverte. Rodrigues, Alex. 2014. Ministério de Saúde estuda distribuir Risperidona a usuários de crack e cocaína. Agência Brasil: 1–5. Rose, Nikolas. 2019. Our Psiquiatric future. Cambridge, UK: Cambridge Polity Press. Sassaki, Romeu Kazumi. 2011. Deficiência Psicossocial. A Nova Categoria de Deficiência. Jusbrasil.. https://oabrj.jusbrasil.com.br/noticias/2748813/artigo-­deficiencia-­ psicossocialromeu-­%0Akazumi-­sassaki. Accessed 25 May 2022. United Nations. Convention on the rights of persons with disabilities. 2006. https://www.un.org/ development/desa/disabilities/convention-­on-­the-­rights-­of-­persons-­with-­disabilities.html. Accessed 30 March 2022. Vizotto, Luana Paula, and Daniele de Andrade Ferrazza. 2017. Childhood in the hotseat: On diagnostic labeling and the trivialized practice of psychotropic prescriptions. Estudos de Psicologia 22 (2): 214–224. Whitaker, Robert. 2002. Mad in America: Bad medicine, and the enduring mistreatment of the mentally III. New York: Basic Books. ———. 2010. Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Crown: Random House. ———. 2022. Medicating preschoolers for ADHD: How “evidence-based” psychiatry has led to a tragic end. Mad in America, February 19. https://www.madinamerica.com/2022/02/ medicating-­preschoolers-­for-­adhd-­leads-­to-­tragic-­end/. Accessed 10 May 2022.

Chapter 10

“So That in the Practice of Good Manners, She Will Find a Dignified and Happy Life”: Institutional Practices Towards Incarcerated Women (Brazil, 1930s) Viviane Trindade Borges, Fernando Salla, and Carolina Wanderley Van Parys de Wit

Abstract  In this chapter, we sought to analyse the practices of female imprisonment in Brazil between the 1930s and the 1950s. This period is crossed by an intense public debate about the possible ways to punish sentenced women, regulated in part by the uncomfortable and more accentuated presence of women in police occurrences and courthouses, as well as by the absence of proper institutions for women who until then remained in male prisons in specific cells or wards. With these debates are the entangled strands of legal and criminological thought, as well as moral and religious conceptions that claimed precedence in the proposition of prison treatment to be assigned to female offenders. Keywords  Female imprisonment · Punitive practices · Criminology · Penitentiary of Florianópolis · Proper facilities for women

This research was supported by Fundação de Amparo à Pesquisa e Inovação of the state of Santa Catarina – FAPESC (Universal Public Notice 12/2020) and Conselho Nacional de Desenvolvimento Científico (project CNPq/MCTI/FNDCT n. 18/2021). V. T. Borges (*) History Department of Santa Catarina State University (UDESC), Florianópolis, SC, Brazil Conselho Nacional de Desenvolvimento Científico (CNPq), Brasília, Brazil F. Salla Centre for the Study of Violence at São Paulo University (NEV/USP), São Paulo, SP, Brazil C. W. V. P. de Wit Santa Catarina State University (PPGH/UDESC), Florianópolis, SC, Brazil Cultural Heritage Laboratory (LABPAC/UDESC), São Paulo, SP, Brazil © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. P. Barbosa-Fohrmann, S. Caponi (eds.), Latin American Interdisciplinary Perspectives on Bioethics and Disabilities, The International Library of Bioethics 102, https://doi.org/10.1007/978-3-031-22891-9_10

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10.1 Introduction The purpose of this chapter is to analyse some practices of female imprisonment in Brazil between the 1930s and the 1950s. This period is marked by an intense public debate, especially among jurists, physicians, and criminologists, about the possible ways of punishing women because of the crimes that were committed. To a large extent, this debate was motivated by a greater presence of women in police occurrences and consequently in the courts where the sentences that condemned them to prison were issued. The debate was also motivated by the absence of proper facilities for women, who until then had remained in the facilities for men, in specific cells or wards. And yet, in this debate, not only strands of legal and criminological thought but also moral and religious conceptions disputed the precedence in the proposition of prison treatment to be imposed on female offenders. Since the end of the nineteenth century, the country has experienced strong population growth and intense urban densification, where new ways of living and sociability have been developed, especially in the main urban centres of the country, such as Rio de Janeiro, São Paulo, and Salvador. Such transformations resulted in a more prominent presence of women in the public space, in the composition of the labour force in factories, and also in the circuits of illegal activities that were the target of repressive actions by the police. In face of a greater presence of women in the public space, in illegal activities, and also in prisons, in the first decades of the twentieth century, even if this presence was smaller in number than that compared to men, it triggered a broad concern in the legal, medical and criminological fields, as well as from the authorities about the paths to be adopted in the management of criminality and punishment for women. Amidst this set of ideas that cross criminological readings, religious and traditional conceptions, women’s imprisonment became more and more the object of political disputes and State interventions which ranged between the direct management of prisons by the State itself or entrusting the recovery of female offenders to religious institutions (such as the Congregation of Our Lady of Charity of the Good Shepherd of Angers) which, in various parts of the world, maintained asylums for the recovery of female offenders and prostitutes or directly managed female prisons. In Brazil, a consensus was reached on the need to remove women from male prisons and to create proper facilities for their imprisonment. In this chapter, we will analyse the experience of female imprisonment in the city of Florianópolis, Capital of the State of Santa Catarina, where, throughout the period from the 1930s to the 1950s women continued to be imprisoned in male facilities. To describe the conditions in which those women were subjected, we rely on the records of the prisoners of the Penitentiary of Florianópolis, whose documentation allows us to prospect the judicial, administrative, and disciplinary practices that crossed the daily life of those women. Other relevant sources for this chapter are the official documents, such as government reports, statistics and legislation.

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10.2 Criminology As in other countries of the West, in Brazil, the writings of Cesare Lombroso had great prominence and acceptance by jurists, physicians, and criminologists. It is in his work about criminal women that we can observe how the figure of the criminal represented a deviation in the behaviour of normal women. The book Criminal Women, the Prostitute and the Normal Women (Lombroso and Ferrero 2004) written by Lombroso and Guglielmo Ferrero (Rafter and Gibson 2004), explains this relationship. To define criminals and natural-born prostitutes, Lombroso takes up the figure of the normal woman, her characteristics, deficiencies, and functions. For the author, the common woman has only one function in society, procreation. They are considered inferior to men, less intelligent, comparable to children, affirming: “What differentiates a woman from the child is the maternity and the compassion; thank those, she does not like evil for evil (unlike the child)” (Lombroso and Ferrero 2004, p. 80). Positivist criminology will reinforce the perspective of this feminine social role linked to the domestic, familiar, and submissive world. The notion of the criminal woman, who rejects maternity, who acts out of sexual impulses, was part of the imagination of jurists, judges, physicians, and wardens of the institution. It was considered necessary to find a way to regenerate and reintegrate those women into society. However, unlike men, the return to society would not be through work, in the figure of the disciplined worker. The disciplined woman was the one who understood her role in society, the one focused on her house. This imaginary, that of the housewife who should only be occupied with raising her children, was, in fact, impossible to be reached by women from the most vulnerable layers of society, who needed to work to contribute to the income and support of the household. However, even the working woman had to follow this profile, creating a family nucleus and adapting to specific gender-appropriate jobs. Although by the end of the nineteenth century Lombroso’s ideas were harshly criticized in Europe, Brazil, and even in Latin America, his ideas continued to be successful. Brazilian physicians and jurists embraced Lombrosian criminal anthropology in their studies and propositions of laws and codes, but mainly in the adoption of the routines of prison institutions. Marcos Alvarez (2002), states that these theories arrived in Latin America in a context that addressed several political and social concerns of local elites. The claim that this criminology constituted a scientific debate was one of the elements that justified its use as a reference for the reading of criminal and penal issues. Its scientific theories would guarantee to physicians, jurists, criminologists, and law enforcement officials a status of legitimacy. In the case of Brazil, the Lombrosian-oriented criminology that was present in the first half of the twentieth century was an important reference of ideas that combined with the social and moral conceptions already existing in Brazilian society to guide how deviant women should be treated. The penitentiaries and punitive

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practices will express this combination of conceptions aimed at seeking the most efficient ways to discipline deviant female bodies. It was important to guarantee the return of women to society, but a controlled vigilance and regulated return, in which the public sphere should be reserved for men, while the private sphere was reserved for women. In this sense, criminals should leave prison ready to return home and to their families.

10.3 Women’s Imprisonment in the First Decades of the Twentieth Century In the first decades of the twentieth century in Brazil, jurists, criminologists, and authorities found that the imprisonment situation experienced by women was far from what was considered adequate. In his book A unissexualidade do regime penitenciário  (Bastos 1915), José Tavares Bastos pointed out the need to create specific spaces for female criminals, because, according to him, the idle state in which female prisoners stayed in mixed prisons resembled ‘vacation’ and this condition made it impossible for them to regenerate. Lemos Britto, in his collection of reports entitled Sistemas Penitenciários do Brasil  (Britto 1926), published between 1924 and 1926, elaborated as a result of visits made to several prisons in Brazil, stated that criminal women – although few – were in a state of calamity and proposed a female penitentiary model similar to the one in the United States, where women would do domestic work, embroidery and learn music, providing the necessary occupation to put an end to the ‘idle’ state in which they found themselves. Lemos Britto sustained that: “What for the young man is the workshop, for the young woman is her home. This is why they are given preference for domestic occupations, such as washing, sewing and running a household, without forgetting the work in the countryside which invigorates their health” (Britto 1926, p. 291). Female imprisonment was both a form of criminality control, but, above all, a form of punishment and also of moral discipline. Until 1940 there was no specific legislation about female imprisonment in Brazil. It was only with the Penal Code of 1940 that a minimum guideline was legally created for female imprisonment when it pointed out in its article 29, § 2°, that: “Women must serve their sentence in a special establishment or, in the absence of this, in a suitable section of a common penitentiary or prison” (Decree-Law No. 2.848 of September 7 1940). To better comply with such legal regulations, but also to carry out the moral disciplinary plan, female penitentiary projects that were discussed in the first half of the twentieth century placed their management in the hands of the Congregation of the Good Shepherd nuns. The idea was that these institutions would be entirely for women, with women prison guards and workshops that best incorporated women’s work: sewing, cooking, and laundry. It was also considered to build female prisons far from the city downtown, in the countryside, so that women could practice

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gardening and labour therapy. The first female prisons were organized in the States of Rio Grande do Sul (1937), Rio de Janeiro (1941), and São Paulo (1942), and placed under the management of the Congregation of the Good Shepherd (Lima 1983; Artur 2011; Angotti 2012). Placing the punishment and care of criminal women in the hands of nuns showed the moralizing character that female prisons should have. Sentences, punishments, and punitive practices in the female universe carried with them a difference concerning the male system, which is that of the applied practices’ morality. To discipline women was to impose on them the domestic world, the understanding of their place in society as belonging to the private sphere, of the home, of family ties. Because of this, the control of these institutions by nuns was configured as a unique punitive mechanism. Although this imprisonment project has materialized in some capitals of the country,1 many women in other States continued to be sent to serve time in male penitentiaries, public jails, police stations, and others. Even after the Penal Code of 1940 came into effect, it is possible to find data and documents that demonstrate the continuity of female imprisonment in male penitentiaries. We will now deal with female imprisonment in the city of Florianópolis (Capital of the State of Santa Catarina), South of Brazil. In the 1930s, the State did not have specific prisons for women and those who were convicted were sent to the Penitentiary of Florianópolis, which was mostly male. It illustrates the conceptions of female criminality present in the legal environment but also reveals the administrative arrangements, not always legally supported, which were adopted to manage female imprisonment and allow us to observe how criminological discussions were mixed with moralistic conceptions to weave the institutional practices of female confinement.

10.4 The Deviant Segments in the State of Santa Catarina: Women’s Situation The Penitentiary of Florianópolis was founded in 1930, in line with the already mentioned network of institutions of social control aimed at the ‘deviant segments’. It is in this period that the local oligarchies started to show concern with the population that was in the streets and needed to be controlled and monitored. Underage children, women, insane people, workers, vagrants, beggars, prostitutes, and criminals in general. Thus, some institutions began to be designed to house this population and better manage them. In the State of Santa Catarina, such initiatives were driven mainly during the administration of Nereu Ramos (1935–1945), when the Penitentiary of Florianópolis was created. After 1930, the network of institutions included Hospital Colônia Santana, for psychiatry; Hospital Colônia Santa Teresa,  These are Porto Alegre, State of Rio Grande do Sul, São Paulo and Rio de Janeiro.

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for leprosy; shelter for minors, among others. Until the 1950s, the Penitentiary of Florianópolis received adults and minors of both genders.2 Despite the consensus that throughout the first half of the twentieth century there was a need to remove women from the male prisons and to create specific facilities for their imprisonment, between the 1930s and 1950s, women continued to be confined in male prisons in the State of Santa Catarina. The facilities for social control remained basically under the direct management of the State. In the absence of specific institutions for minors and women, both ended up in common male institutions with legislation’s consent. In practice, the separation that should be guaranteed was limited by institutional logistics and in the function of its problems, both physical and administrative. In the case of women, and especially the minor girls, the contradictions were even greater, since the confinement occurred inside male penitentiaries, in spaces that did not always allow the total separation of the bodies. Among the 23 records of women that were found, two of them were from minors. A universe that is significantly smaller than the number of men, which makes up a total of 1158 records for the same period. This relatively small number of records of convicted women concerning men certainly corroborates the stereotypes that confer on women an ‘inability’ to commit crimes, a thought that was defended by criminologists and jurists of the time. To think about these deviant segments and the institutional practices that used to weave the daily life in the State Penitentiary of Santa Catarina, the prison records are fundamental sources. We will use general information brought by these sources, making one of them our guiding thread. Through the prison records of the inmate Eliana,3 imprisoned in 1934, we seek to understand the currents of thought that influence both the punishments and how the Penitentiary was run. Eliana was convicted of murder after poisoning her parents, causing the death of her mother. The prison records, although incomplete, allow us to understand which paths were taken for the conviction of the inmate. In the guide letter, it is possible to see two versions of the crime. She is categorized by the judiciary as a rebel who goes against her parents’ decision and lives a promiscuous life. On the other hand, Eliana affirms that she was being abused. It is important to point out that her guide letter does not bring enough elements to verify how the judge constructed the statement that the young woman was a prostitute, but it is clear that his thinking is  From the inauguration of the State Penitentiary in 1930 until the creation of the Underage Children Shelter in 1940, minor offenders between 14 and 18 years old, sentenced for having committed some type of crime, were sentenced to common prison. According to Fernando Torres Londonõ (1996), from 1920 onwards, the word minor “started to refer to and indicate the child concerning the situation of abandonment and marginality, besides defining his/her civil and legal condition and the rights that correspond to him/her”. The term came to indicate “mainly poor abandoned children or those who committed crimes” (Londonõ 1996, p. 129). 3  The names of all the people involved in Eliana’s story, including her own, have been changed to pseudonyms, to preserve their identity and guarantee their right to be forgotten. The Public Authorities (Directors of the penitentiary, doctors, judges and others) involved in the case, will be named by their real names. 2

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strongly influenced by Positivist criminology, thus, his view of criminal women carries the insignia of these positivist discourses. Eliana’s passage through the institution highlights the pejorative character of the discourses that sought to institute some women as perverts and prostitutes. The way Eliana is engendered by this discursive web connects her to the struggles related to the history of women within the Brazilian prison system even today, issues that are still being debated in research from the most diverse areas of knowledge. The fact that she was a woman was a determining factor in her exclusion and the peculiarity of her existence in the prison space. Eliana’s prison records contain a huge and diverse set of documents that weave a web of complex meanings. The crime committed by her seems to have shocked not only the community where it occurred but also the law enforcement agents and the prison institution. According to the opinion of the Penitentiary Board, in 1937, “The case in question is, without a doubt, one that deserves more thorough attention, and it would not be too much to say that it would be worthwhile to study in the light of psychoanalysis” (Idch, 1934, n. 164). The prison records enable several analyses regarding different aspects of institutional practices. Here, we intend to observe how the institutional practices were shaped to attend to the female public. Thus, it is necessary to understand how the judicial system, the wardens, the prison guards, and the prison board categorized and classified these women, and how they resorted to medical-legal theses to justify their actions. Eliana was 15  years old when she was admitted to the Penitentiary of Pedra Grande in 1934, sentenced to 7 years in prison for the attempted murder of her parents. Although she was sent to an adult penitentiary, as a minor she should have been sent to a reformatory school, a disciplinary institute, as determined by the Decree Law No. 17.943 of 1927, commonly known as ‘Minors Code of 1927’. In his sentence, the judge labels Eliana a ‘perverted individual’ and presents his arguments: By perverted individual is to be understood, since this personal condition can only be observed and declared in a particular case, after a complex of facts and circumstances appreciated by the acting Judge. By the text of the Law, one deduces, however, the notion that the dangerous and perverted state exists when the criminal offense can be presumed, proven from the intellectual nature and moral character of the minor, that the minor, due to the degree of perversion is not susceptible to remediation and is likely to commit a new criminal offense, if the ordinary penalty is not imposed on the person. In evaluating the seriousness of crime the Legislator has not only taken into consideration the importance of the individual or social asset upon whom the risk of injury is directed, but also the circumstances surrounding the crime, the quality, quantity, the intensity of the psychic causes that produced... The Judge’s mission is, therefore, to appreciate more the character, more or less antisocial of the perpetrator, the degree of intensity, of the implicit and unjust motive that drove the perpetrator, rather than the materiality of the fact, the danger subjunctive to the criminal capacity of the agent, revealed by his temper, perverse or bad behaviour and habits of life, or personal [?] background, which denote in the perpetrator a predisposition to commit a crime, or make one suppose that he/she will commit new crimes (- emphasis added by the authors) (Idch, 1934, n. 164).

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The arguments presented by the Judge have some traces of the Lombrosian thought regarding the biological determinations, the atavistic disorders that indicate the future possibility of new delinquent actions. In the Minors’ Code of 1927, it is common to use the expression for minor to be ‘perverted’ or in ‘danger of being so’ (Borges 2016), indicating the future delinquent potentiality, justifying that he/she should be sent to correctional institutions (Rizzini 2011). It is from the guide letter that functions as a summary of the judicial process that we can observe how punitive practices begin to shape themselves to act on women. Eliana’s trial took place in Cruzeiro County4 and was presided over by Judge Luiz Augusto de Otero. The police investigation opens the possibility of two motivations for the crime committed by Eliana: the first was the fact that she wanted to marry her boyfriend, a situation that her parents did not agree with and did not give her permission for, considering that she was a minor. The second reason would have been the mistreatment she claimed to have suffered from her parents. However, when reading the sentence, the Judge and the police officers did not consider the minor’s version or even the hypothesis of motivation due to an unauthorized marriage. Indeed, the Judge makes the following observation: “It is also proven in these records that the accused, despite her young age, is already perverted and is a prostitute” (Idch, 1934, n. 164). Throughout the sentence, several times, the Judge points out testimonies about the accused’s sexual life. At one point, he says: “The defendant woman, as can be seen from the testimonies, is not satisfied with having sex with just one man, because she usually dates several” (Idch, 1934, n. 164). The ‘materiality of the fact’, that is, what the subject had indeed done, the crime committed, lost relevance when compared to what it represented or could come to represent. The ‘criminal capacity’ of the offender, her ‘perverse nature’, her ‘bad behaviour’, her ‘habits of life’ and her ‘background’ were taken into consideration. All of these listed points made the Judge assume that the minor in question ‘will commit new crimes’. However, the application of the ordinary punishment determined by the Judge supposedly could prevent the continuation of this dangerous and perverted state. It is explicit in the sentence that the materiality of the crime is not the only thing that the Judge in charge of the case was paying attention to. Much more than the crime itself, the records and the sentence focus the investigation on Eliana’s moral character. The case is then personified and the judiciary looks at her personality traits, investigating possible forms of “mental alienation and disability” and stating that the detainee is not “epileptic” (Idch, 1934, n. 164). In any case, the Judge had ample authority over minors’ internment, which could last for ‘the necessary time for their education’, a time that would be measured and determined by the Minors Judge and could not surpass 21 years of age, according to the Minors Code of 1927. In the case of the minor in question, in addition to not only applying the Law when judging the committed crime, but the Judge also insisted on classifying her as

 The District of Cruzeiro is currently known as Joaçaba, located in the Midwest of Santa Catarina. In 1940, according to the demographic census, Cruzeiro had 36,174 inhabitants (IBGE 1940, 51). 4

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a prostitute. As said previously, much of what was written about female delinquents was inspired by Lombroso’s work, in which the author pointed out that women with a sexual life considered to be outside the standards of the time possessed degenerative traits that could lead them to commit crimes. Cesare Lombroso strongly advocated that the penal system should focus on the criminal and not on the crime itself. In this sense, the very verification of a possible epileptic trait, such as the one shown in Eliana’s sentence, demonstrates an alignment with Lombrosian theories, since he points out that epilepsy can be one of the factors that would lead women to criminal action (Lombroso and Ferrero 2004, p. 70). In his sentence, the Judge does not mention Lombroso’s name, but it is clear the repercussion of such discussions in the document, not only pointing out elements of Eliana’s sexual life but also establishing probable dialogues with Lombroso’s theses. At a certain moment of the sentence, he states: “For society, it is not the crime that is dangerous, but its author” (Idch, 1934, n. 164). The notion of regeneration directly influenced jurists, physicians, and the Penal Codes – here, more specifically the Minors Code of 1927 (Alvarez 2003). In Eliana’s sentence, the Judge maintains that she possessed a “state of moral perversion that could only be regenerated in a reformatory institution” (Idch, 1934, n. 164). In the State of Santa Catarina, there was no reformatory institution for minors known as delinquents; thus, minors who committed crimes were sent to the Penitentiary of Florianópolis, whose imprisoned population was composed of adult men. There was also no penitentiary institution exclusively for women. Therefore, the Judge requested that Eliana had to be sent to the Penitentiary: “Separated from the adult convicts and subjected to the appropriate disciplinary and educational regime” (Idch, 1934, n. 164). Her trajectory in the Penitentiary of Florianópolis reveals an effort by the institution to establish punitive practices exclusively for women. Part of her sentence was served at the prison guard’s family home at São José Public Prison. Although it was a common practice applied to the inmates inside the Penitentiary, it was never registered as a judge’s determination, being an internal punitive arrangement, unclear and undocumented, apprehended only through sparse records found in the minors’ and women’s prison records. It is due to Eliana’s prison records, more specifically when she requests parole, that we can observe these distinctions between discourse and practice. In 1934, a Judge requested Eliana’s transfer to São José Public Prison. However, upon her arrival in São José, the minor was sent to serve her sentence in the house of a prison guard (Idch, 1934, n. 164). This was not a practice provided by Law, and there was nothing to regulate the decision of the Penitentiary warden, who at the time was Edelvito Campelo D’Araújo. In the parole file, the head of the penal section Agenor Cardoso wrote: Her transfer to São José Prison was due to a request made by the Judge of Law of the 2nd District Court of this Capital [...] By the certificates of the prison guard and the Police Chief of the Municipality of São José, it is clear that she was entrusted to the custody of the first one, and the intention of the Judge of Law of the 2nd District Court of this Capital could not have been any other when he requested her transfer to São José Prison [...] And let’s tell the

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truth. In the current Penitentiary, we cannot house female prisoners due to the environment and lack of rooms (Idch 1934, n. 164).

The transfer to São José Public Prison was a measure requested by the Judiciary; however, the transfer to the house of a prison guard was an extralegal measure, not foreseen in any other legislation, much less in the Penal Code. Why would the house of a prison guard be a more suitable place for a woman to serve her sentence than in a penitentiary institution? This arrangement suggests that it sought to corroborate the role instituted to women in this society. While men were granted the public space, women were left with the household and the care of the family in a gendered division of spaces (Rago 1997). Thus, as the categorizations of the criminal woman intended to have a scientific character, the categorization of the female space in society also had this character that determined the woman - biologically - the home and the family as a space of agency. Therefore, sending a woman to serve time in the house of a prison guard was in line with this logic, in which the regeneration of women should happen from domestic work. Eliana herself appropriates this discourse to apply for parole, claiming: “Once the benefit is granted, she declares she wishes to reside in Cruzeiro do Sul District, dedicating herself to domestic services” (Idch, 1934, n. 164). It is not only the social performance space that is affected by this logic; there is also the sexual division of labour (Scott 1991). If the regeneration of criminals happens through work, as defended by the criminologists, regeneration of women happens through housework. By giving its opinion on the request for conditional parole, the Penitentiary Board also acknowledges that Eliana served time in the prison guards’ home. It states that the Penitentiary could not “meet the provisions of the Minors Code” (Idch, 1934, n. 164). For this purpose, the Board members also resort to Positivist theories by quoting Porto Carrera - a physician and Freudian - who believed that regeneration would only happen pedagogically when controlling the criminal impulse. In Eliana’s case, the practice that established family interaction between the inmates and the prison guards’ families was pointed out as something that helped to promote regeneration. This is how the Board expressed itself: It is not proven that Eliana has fulfilled the provisions that would entitle her to conditional parole [Continues on next page]. As to her behaviour, although certain impulses have a temporary character, with periodic outbursts, which makes it difficult to assert that her libido impulses have been exported with the perpetration of the crime, the long permanence in contact with an honest family, the observation of the family, daily, which consider her to be of good behaviour, honest and obedient, may be taken as indicative of her regeneration (Idch, 1934, n. 164).

After serving half of her sentence, her good behaviour led Eliana to request conditional parole. However, it was denied by the Penitentiary Board (August 19, 1937), and she was recommended to request supervised parole, which consisted of: “Keeping the minor in the company and under the responsibility of parents, tutor or guardian, in the care of a patronage and under the supervision of the Judge” (DecreeLaw No. 17.943-A of October 12 1927). It is interesting to note that parole was only

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suitable for adult convicts who had been convicted of offenses under the Penal Code of 1890 (Decree-Law No. 847 of October 11 1890). Even so, Eliana requested it, since she met the requirements for the request: she had served more than two-thirds of her sentence and had good behaviour in prison. In the recommendation for the minor to apply for supervised release, the Board noted that: “Constant vigilance will prevent her from reoffending, while the measure of clemency will serve as an incentive to her, so that in the practice of good morals she may find a worthy and happy life” (Idch, 1934, n. 164). Eliana’s prison life was highlighted by ruptures and transfers. The beginning of her trajectory was already beyond what was foreseen in the Legislation: the inmate was sent to serve time in an adult male institution. Later, in 1934, she was transferred to an annex section of the Penitentiary, where, in theory, it would be a more appropriate and exclusive space for women. However, in 1938, her prison records showed that Eliana and another inmate fought over male inmates who were housed in the same place. In her first transfer, she did not stay in the facility, because, as already mentioned, the wardens, together with the chief of police, sent her to serve time in the house of a prison guard, an extralegal action and without the approval of the judicial authority. After this period, we can see in the records that Eliana was sent back to the central section of the Penitentiary in Florianópolis to work for 2 months in the tailor’s shop.5 In 1938 she was transferred again to São José Public Prison. After serving her sentence in 1940, she was set free. In her prison records we can see that before she was declared free, she was sent to the Identification and Forensic Medical Institute of the Secretary of Public Security to be booked by the police.

10.5 Final Considerations We sought to analyse some practices of female imprisonment in Brazil between the 1930s and the 1950s, problematizing a period of intense public debate about the possible ways to punish sentenced women. The debate was guided in part by the more prominent presence of women in police occurrences and the courts, as well as by the absence of proper facilities for women, who until then had remained in male prisons in specific cells or wards. Added to these debates are the entangled strands of legal and criminological thought, as well as moral and religious conceptions that claimed precedence in the proposition of prison treatment to be assigned to female offenders. Based on Eliana’s case, we sought to show how the social representations concerning the role of women in society were combined, as well as the criminological ideas that were expressed in the judicial sentences and the practices of the prison  The Penitentiary also had workshops for shoemaking, carpentry, brooms, bookbinding, bakery, and bedding (Baccin 2019, p. 42). These spaces were intended for male inmates, and when women prisoners were present, the workshop became a combined space. Thus, the coexistence between men and women in the Penitentiary of Florianópolis was not divided. 5

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institutions. To a large extent, the Judge’s sentence combines those elements aimed at an understanding of how women offenders acted, as well as the concerns for morals and good manners. Eliana had the intimate aspects of her life exposed and the greatest relevance in the Judge’s decision was associated not with the criminal fact itself, but with the conduct of her sexual life. Once convicted, she was to be sent to a reformatory school or similar institution, since she was a minor. However, in the absence of such institutions, she was sent to the Penitentiary of Florianopolis, intended primarily for adult males. She was then placed in another prison, but in fact in a prison guard’s house, in the absence of any legal provision or court decision. But her relocation to a home represented the imposition of a penal, regenerative ‘treatment’ that recognized the domestic environment as a determinant for her return to society. In summary, we can understand that although the Penitentiary of Florianópolis worked in a mixed way, being administered by representatives of the State Authority, the institutional practices and the way of punishment resembled the punishment methods desired by jurists, physicians, and criminologists of the period. The Penitentiary did not follow the proposed methods, it was not the ‘ideal system’, exclusively feminine, administered by nuns and with specific workshops for women. However, the way the institution worked to put into practice the main criminological doctrines and tried to adapt the Penitentiary space to receive women. Whether it was checking the morality of the criminals, sending them to serve their sentences in the prison guards’ house, or putting them to work in the internal care of the Penitentiary, the institution tried to guarantee a disciplinary process based on the proposed methods. Historical Sources Penitentiary of Florianópolis, “Prison Records”, IDCH, Penitentiary Archives, No. 164, 1934

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