Vasconcelos, Eduardo Mourao
(1992)
New alienists of the poor: Developing community mental health services in Brazil, 1978/1989.
PhD thesis, London School of Economics and Political Science.
Abstract
This thesis constitutes an investigation of the development of community mental health services in Belo Horizonte, Brazil - although information on two other cities, Rio de Janeiro and Sao Paulo, is used for contextual comparison. The study addresses two main issues: a) the possibility of successful psychiatric de-institutiona1ization in a Third World country, where most of the historical conditions which allowed such processes in First World countries are, in general, not yet developed; b) an evaluation of the hegemonic service models being implemented and their appropriateness to the clinical needs, class and cultural background of clients of these new services. The research strategy uses 'multiple and embedded case study design', involving historical, ethnographic and survey methods. First, the historical account traces the development of the mental health movement and of implementation of services between 1978 and 1989 and its political, economic and social basis. Second, the hegemonic service model being implemented is analyzed through original data obtained by fieldwork to assess its determinants and implications for the clientele. The results suggest that services in Belo Horizonte are marked by economic and political constraints and a professional culture strongly influenced by the private clinic liberal practices. The main implication of these is a very low level of care for the very clients who are given formal priority in the programme: the continuing care client, their informal carers, and the poorest, uneducated client groups. This effect is also found in Sao Paulo and Rio de Janeiro using secondary analysis of existing data. However, the effect is lessened by the availability of a more complex service network. The findings suggest also the inappropriateness of services to the cultural background of the target clientele, and alternative service models inspired by the popular representations of mental life and community practices are examined. Finally, the prospects for the de-institutionalization process in Brazil are discussed, with some suggestions for political action and policy making.
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