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SMAD. Revista eletrônica saúde mental álcool e drogas

versão On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.10 no.2 Ribeirão Preto ago. 2014 

DOI: 10.11606/issn.1806-6976.v10i2p101-109


Psychiatric Reform in Natal-RN: historical evolution and the challenges of nursing care



Fernando de Souza SilvaI; Clélia Albino SimpsonII; Rita de Cássia DantasIII

IRN, Hospital Universitário Onofre Lopes, Natal, RN, Brazil. Doctoral Student, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
IIPhD, Associate Professor, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
IIIRN, MSc, Secretaria Municipal de Saúde, Natal, RN, Brazil





The purpose of this study is to discuss the evolution of care practices of patients with psychiatric disorders in the city of Natal (RN), through an integrative review in which we found six studies on the subject. We believe that the ideas proposed promote changes in mental health nursing care. Among the conclusions we realized the need for better training of mental health nurses, requiring these professionals to support integration of care in order to  promote the transformation of practices, knowledge and cultural values, impregnated in the routine care of clients and their families.

Descriptors: Nursing/history; Psychiatry; Mental Health; Nursing Care.




Historically, psychiatric hospitals were imputed with the mission to exclude people with mental suffering from the social environment. Fostered by marginalization, stigma and prejudice, and justified by the goal of rehabilitating and reintegrating the sick to social dynamics that are more democratic; however, this discourse has been sealed between the walls of nursing homes, practicing unworthy and inhumane care in appalling stuctural and supportive conditions, encouraging precarious therapeutic possibilities, and in the absence of favorable policies coming from the spheres of health management.

As a proposal against the hegemony, psychiatric reform in Brazil arises with the aim to improve the quality of life of patients with psychological distress by: restoring their citizenship and freedom, promoting efficient, effective, and humane mental health care, reducing the number of mental health hospital admissions, encourage family participation equally in rehabilitation and social reintegration associated with the expansion and improvements in outpatient care, as well as the re-evaluation of professional practice.

The state of Rio Grande do Norte is one of the pioneering states in the implementation of the Brazilian psychiatric reform, having been the site of major changes in psychiatric care, opposing movement toward psychiatric hospitals and favoring the expansion of outpatient care(1).

The process of psychiatric reform in Rio Grande do Norte, within the capital Natal-RN in particular, proposes the integration of the efforts of professionals and managers in public health and the co-participation patient's families, with the idea to promote favorable conditions for good practices in psychiatry that is offered in care units and with mental health support(1).

New perspectives are required to assist mental health professionals, before the psychiatric reform proposals, great nursing care was a social change agent, a sponsor of welfare, rehabilitation and reintegration of patients; thus, a greater understanding of the context of psychiatric care offered to the population is necessary for the reformation of care.

This study is justified by the fact that the state of Rio Grande do Norte is one of the pioneers in the movement of Brazilian psychiatric reform(1) and, in this way, the capital Natal is a good reference for groundwork discussions about the development of practices in mental health, allowing, therefore, a better understanding of the current situation of care. This  tends to promote reflection on the optimization and adequacy of treatment of the mentally ill, in the context in which nursing is inserted and committed to provide the care required for these clients, compared to the current legal, technical and humanistic demands.

Therefore, we aimed to discuss the evolution of nursing care practices for patients with psychiatric disorders in Natal, through an integrative review on the subject. We believe that a better understanding of the current context of structural reformulations and subsidized care with the construction of proposed actions will be able to improve care, more specifically in mental health nursing.



This study includes a fragment of a dissertation from the Nursing Graduate Program, in the Nursing Department, at the Federal University of Rio Grande do Norte, entitled Stories of psychotropic user's lives: the nursing challenge of caring. It was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte under the protocol 198/2009.

In this study, we carried out an integrative literature review, in order to investigate which scientific papers were published on the theme of nursing care for patients with psychiatric disorders in the historical and current context of reformulation of mental health care, especially in the state of Rio Grande do Norte.

We chose to use the integrative review because of its potential synthesis, categorization, evaluation and assessment of the scientific knowledge produced on a given theme(2); thus, it is the appropriate method to achieve the objectives proposed by this study.

This synthesis enables the contextualization about the theme and identifies the gaps that need to be filled with new studies, contributing to discussions about the methods and results of previously published research(2); as a result, there was a search in databases including the Virtual Health Library (VHL), Lilacs and Medline, between the years 2007 and 2012. The choice of these databases is due to the fact that these encompass national and international publications of great impact.

The search for articles was done from March until June 2012, which combined and randomly used the keywords, presented between Descriptors in Health Science or DeCS (Descritores em Ciências da Saúde), "History", "Psychiatry", "Nursing" and "Mental health."

The inclusion criteria for the articles were those who wrote about the psychiatric reform process in Brazil and in the state of Rio Grande do Norte, addressing nursing and mental health in this context of construction and redesign. We included studies published in databases and research, with up to five years of publication, in Portuguese, English and Spanish. To verify that the articles met the inclusion criteria, an evaluation was carried out by two independent reviewers, through the preliminary reading of the abstracts and subsequent full manuscripts.

The articles found were organized into the categories: title, objectives, results, main conclusions and references of each study, in order to summarize the information in a concise way, forming an easily accessible and manageable database.



The search of the databases and research showed a total of 12 articles with the use of the descriptors; however, there were six articles selected that met the inclusion criteria of this study, that promoted discussion on the specific topic, two of these were published in the year of 2011, two in 2010, one in 2009 and another in 2007.

Figure 1 shows the relationship between published works about the process of psychiatric reform, in particular in the city of Natal-RN, in which nursing is introduced in the context of care of the mental health patient, as evidence by the incipient quantitative studies in the area of psychiatric nursing in the State of Rio Grande do Norte.

The beginnings of psychiatric care and its evolution

The process of psychiatric reform began in Brazil in 1970, constituting the struggle for better quality of care in mental health, with the aim of transforming the hospital-centric model of psychiatry and existing asylum. Born in a period that required profound political changes that pointed to the democratization of the country, concomitant with the sanitary movement, a desire to reshape the relations of patients in health services and health promotion was established(3).

In 1857, the beginnings of Natal psychiatry started with the construction of a lazaretto hospital, characterized as an institution for lepers; however, the lazaretto hospital lacked specificity and commonly served people with diseases that stigmatized them and society labeled as social scum. Thus, cases that were incurable, such as tuberculosis, syphilis, smallpox and those with psychiatric disorders, were cared for there(3-4).

In the lazaretto hospital, patients with psychiatric disorders were subjected to humiliating and inhumane conditions, crammed in together and exposed naked or even chained. Young, old, men, women and children suffered abuse and rarely returned to social life. In some cases, the institution worked to ensure the necessary confinement of madmen, excluded from society those with coping behaviors believed to be dangerous(5).

In 1882, the lazaretto is now called the Natal Mercy Lazaretto Hospital, still running without therapeutic procedures appropriate for the reintegration of patients into society, but with little focus of removing the segregated from the streets. In 1911, the Natal Mercy Lazaretto is now called the Mercy Asylum, but with the same execrable pile configuration of social "scum," the term abominable and stigmatizing(5-6).

In 1916, Dr. Varela Santiago practices in Mercy Asylum, despite not being a psychiatrist, he begins to realize that patients with mental disorders are patients who also need health care, but the medical practices of the time were not resolving and only increased suffering and mistreatment of hospitalized people. The therapeutic options were solitary confinement, physical restraint with straight jacket and restraints that caused abscesses leading to serious infections(7).

Under the direction of Dr. Varela Santiago, in 1921 the Mercy Asylum is now called the Natal Insane Hospital, using the same building, the same facilities and continued to humiliate and degrade inmates. The name changed as years went by, but the intent of the site lasted, with confinement, segregation, abuse and death of patients as the final trajectory of their lives(3-4).

In 1936, the newly laureate in medicine returns to Natal, the doctor/psychiatrist João da Costa Machado, influenced by the revolutionary ideals of psychiatric professor Dr. Ulysses Pernambucano, who proposed to break the old methods of mental health care by encouraging rehabilitation and humanization as the primary focus of psychiatric therapy(3,5).

Dr. João da Costa Machado proposed a revolution in psychiatric care in the state of Rio Grande do Norte by: defending the reformulation of patient care, creating art workshops within the Natal Insane Hospital, performing medical and social outpatient treatment, as well as seeking out outpatient care and not hospitalization; however, the state government had not accepted this contradictory movement to the hegemonic model of the time and exonerated the doctor(3).

Using his influence and persistence, Dr. John Machado continued his struggle for the restructuring of Natal psychiatry; he organized scientific events, provided professional training, created public awareness about the new health care model, included the psychiatric discipline in the curriculum of Social Work, complained of the ill-treatment of patients, and finally, in 1957, constructed the Colony Hospital of Psychopaths, later renamed Hospital João Machado, in honor of its founder(3,6).

João Machado Hospital received patients from the Natal Insane Hospital and started its activities, before the new model of social reintegration and rehabilitation of those patients, the Natal psychiatry is renovated, until the death of Dr. John Machado in 1965, which brought profound transformations. Gradually, the lazaretto scenario was rebuilt due to neglect and lack of government commitment to maintain the colony functioning properly, forthcoming years depreciation(3,8).

Between 1980 and 1990, one psychiatric reform movement appeared in Natal, made up of industry professionals, engaged in the then Health Department created by the city, which, in 1987, incorporated psychologists on their staff. These psychologists, along with nurses, doctors and social workers, were leading the fight against imperium, translated in the project Reorganization of Mental Health Care Proposal in the city of Natal(3-4).

In looking at the historical progression of psychiatric reform in Rio Grande do Norte, it is important to highlight the inauguration of the new mental health care model in 1992, implemented by the Health City Secretary of Natal-RN, it created the Psychosocial Health Center, authorized by the Ministry of Health, by Order 224 on January 29, 1992, it became the local Psychosocial Care Center (PCC) and regional Center of Care for Health Professionals (CCHP), targeting customer with mental disorders(8).

In October 1992, the anti-asylum movement gained momentum after the 1st Municipal Conference on Mental Health in Natal-RN, in partnership with the Federal University of Rio Grande do Norte, five hundred professionals participated with the support of the Ministry of Health; formally organized in the same year, the resolutions of the 2nd National Conference on Mental Health, called for the formation of an integrated mental health network that would substitute the services of psychiatric hospitals(7).

In November 1992, the proposal for the reorganization of mental health care in the city of Natal-RN was released, through an integrated management system, where mental health care starts at the primary, secondary and tertiary level, complemented by specialized clinics, 24 hours call centers, psychiatric bed availability in general hospitals, psychosocial care centers, and protected shelters(3,7).

Other events that were extremely important to the psychiatric reform in Natal, was the 1st Mental Health Professionals Seminar in 1988 and the implementation of the Mental Health Program at the Pirangi Health Center in 1994.

In 1994, the first implementation of CCHPs happens in Natal, located in the eastern part of the city, with capacity for sixty patients, although, the demand has now exceeded the services supplied. Continuing on until today, the result is the creation of a waiting list for new patients, generating local difficulties when needing to refer patients to the mental health center(3,8).

In the development process of Brazilian psychiatric reform, Rio Grande do Norte enacted the Law 10.216 / 2001, by the state Law 6758, on January 4, 1995; this law prohibits the construction and expansion of psychiatric hospitals in the state, except for works that were intended to provide improvements, modernization and adjustments of structures and facilities, only approved by the City Health Department(3,9).

In 1995, the CCHP and PCC were deployed to the western region of Natal-RN, the latter being for the exclusive care of drug addicts and alcoholics. In 1997, the Day Hospital (DH) was created, which, for nearly ten years, provided an average of 1,800 calls. Among the DH objectives, improving the transition between the hospital system and the home stood out, preventing relapses during treatment and complete hospitalization. During this type of care, individuals were encouraged to return to social life as soon as possible(8-9).

Even though it immensely contributed to the strengthening of good practice in mental health, the DH ended in Natal-RN in 2006, with no apparent political or economic explanation for its termination, it was reflected dramatically in the lives of the patients, their families and psychiatric professionals. Currently, the DH's building is now the Detoxification Unit (DU), for the increasing incidence and prevalence of drug and alcohol users, previously nonexistent in the Natal public health system. The Drug and Alcohol Treatment Unit (DATU) in  the Onofre Lopes University Hospital, is another service that was developed for the same job in the state of Rio Grande do Norte(9).

Data from the east and west CCHP in Natal, between 1994 and 2001, demonstrate significant progress in reducing the number of traditional psychiatric admissions. Prior to the creation of the CCHP, 50% of new patients did not require hospitalization, but after its creation, it was observed that 82% did not need to be hospitalized.

Rio Grande do Norte ranks eighth place in CCHP coverage/100,000 inhabitants per Federation Unit. The State Government and the Public Health Department (State Secretary of Public Health SSPH) have 572 psychiatric beds available(10).

While these numbers are encouraging, the effectiveness of psychiatric reform in Natal is under construction, the difficulties noticeable, such as restricted access to primary, secondary and tertiary units, prolonged treatment time, increased demand, lack of effective social reintegration policies, and stigmatization and prejudice(8).

Psychiatric admissions after the creation of CCHP, according to the professionals of these centers, occurs mostly due to lack of treatment resources such as beds in general hospitals and 24 hour care centers in times of client crisis(3).

The process of psychiatric reform in Rio Grande do Norte develops among problems caused by the conflicts of political interests, diversity of opinion between health professionals, the maintenance of the asylum culture, and serious financial and institutional barriers(10).

The integration of the Family Health Unit and mental health services is another important tool, making Psychiatric Reform effective in Rio Grande do Norte. However, there are several barriers that hamper the process of change within mental health practices including: the biomedical model, the overvaluation of the use of psychotropic drugs, the fragmentation of health care, poor allocation of financial resources, poor expansion and job training, and the absence of service evaluation mechanisms(11).

The existence of substitute services in psychiatric institutions is not the fulfillment of Natal's Psychiatric Reform. Therefore, from a practical perspective, simply changing the instruments the new proposal requires has no value without qualified human resources that are committed to the health care changes.

Nursing and mental health: the face of care.

In Natal, specialized services of care of the mentally ill, have mostly been carried out in daily care by an active nursing staff who are committed to the proposals of the psychiatric reform, but without autonomy and with little scientific background(3). There is possible evidence of this reality in the few scientific publications presented in Figure 1.

Nursing has ties that are rooted in the origin of this profession when there was an integration with psychiatry; the care system, the theories, and the questionable knowledge of science weakened the nurses actions in mental health in favor of autonomy, specialized practice, and scientific focus, contributing to a visible crisis in the services provided to mentally ill in Rio Grande do Norte, especially in Natal-RN(3,12-13).

Mental health nurses may be repeating the same mistakes they made in the early days of psychiatric nursing, they need to stop attending to the physical demands and succumb to their potential in care, kicking in the construction, and reaffirming nursing as a science(13).

The good point, and probably the most important one, is that mental health nurses in Natal have the commitment and the interest in changing the context of care, they relate well with clients and their families in a reliable and caring duality, this appears to be a giant step toward the humanization of care(3,8,14).

The work of mental health nurses has few incentives and opportunities for strengthening their health care practices, especially in the absence of continuing education programs in this area(3,5).

The social, the scientific and the humanistic role in the course of nursing has led to the formation of this profession, now it is aimed at strengthening the implementation of the psychiatric reform in Rio Grande do Norte, the perception of the nursing students is to engage in renewing these care practices(10).

The integrative review presented here strengthens the discussion about the process of psychiatric reform in the scope of regionalism. However, if you consider the source of these debates on the refomulation of nursing care in mental health, there is substantiating evidence for this information included in this study.


Final Considerations

Psychiatric reform cannot be restricted to promoting deinstitutionalization of psychiatric hospitals. Thus, there is a need to create new centers and psychosocial support centers to help with the consequential increase of patients, reintegrate them into society and rehabilitate them from solidarity within society, not allowing to be on house arrest, or be segregated by stigmatizing acts, but a real daily reformation of the care provided by mental health institutions and, especially, the fundamental social center, the family of these patients.

The discontinuity of the actions proposed by the psychiatric reform is closely related to the political and social commitment, which includes the perception that, in the historical and current context, care of the mentally ill does not constitute a priority of government or society but a latent need of the family to extract their psychiatric patient because of fear, an inability to care for them, or simply stigmatization. Furthermore, public officials are uncommitted to the transformation of care for this population.

Assistance to patients with psychological distress in Natal-RN is offered by an organized network of services, formed by the mental health institutions, general hospitals with unique beds for this population, centers as well as psychosocial care centers, and with the support of the Family Health Strategy; this has considerably decreased psychiatric hospital admissions, but still not enough.

The link between the cores of psychosocial care centers and primary health care should be strengthened with more effective public policies, technical training and scientific preparation of professionals in these areas, and awareness strategies to motivate social co-participation in the process.

The need for greater training for mental health nurses is founded on the exigency of this profession that is in favor of the integration of care; this promotes the realization of the practical transformation of knowledge and cultural values, impregnated in the daily care of these clients and their families, contributing to the optimization of interpersonal relationships, allowing them to intermediate impasses, tensions and conflicts, and finally invest their efforts on the  reintegration and social rehabilitation of these historically victimized people.



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Fernando de Souza Silva
Rua Turmalina, 263
Bairro: Nova Parnamirim
CEP: 59.152-405, Parnamirim, RN, Brasil

Received: July. 27th 2012
Accepted: Dec. 19th 2013