Psychology and the Brazilian Public Health System: Challenges and Opportunities

Posted on Aug 2, 2024 in Social sciences

The relationship between Psychology and the Public Health System (SUS) in Brazil is discussed, taking as its starting point a critique of the separation between practice and policy strongly present in the training and professional practice of psychologists. This article suggests three principles for the construction of public policies in health: inseparability, autonomy and co-responsibility, and transversality. The contribution of psychology lies in the interchange of these three principles. The article also highlights the importance of the ways to make things happen in policy, indicating the urgency in creating devices that support these politics in the game of conflicts of interests, desires, and needs of different actors in the health network.

Bridging the Gap Between Psychology and Public Health

The article’s title already indicates a starting point unfortunately found little in the field of psychology: a public health concern, with the insertion of the work of the psychologist in the debate on intervention methods that go beyond the traditional framings of an individual clinical and private practice, or even a social psychology that maintains the separation between the records of individual and social, as is still prevalent in our training courses. This is not to say that there is a need to critique psychology and its various areas by identifying a conservative side because it focuses on the individual, and an empowering side because it is geared toward the social, the community, educational processes, or work. As I intend to argue here, we should not be deceived by this compromise solution of Psychology.

Especially when we think of psychology’s interfaces with the National Health System (SUS), it is urgent that we question what we do, what we want, and, especially, how we contribute to the construction of another possible world², another possible health, and, I might add, a possible public health.

Rethinking the Role of Psychology in a Changing World

Convened to debate and in line with the resistance movement establishing the World Social Forum since its first release in 2001, I was wondering where to enter it. I could recall the history of psychology, indicating their allegiance to the positivist sciences or the subjectivist philosophies. I could point to the humanist tradition that binds Psychology to the field of Human Sciences, becoming separated from the health sciences. I could also trace the many divisions between chains or between psychology and psychoanalysis, each marking and appropriating the subject as its object of investigation.

There is no need to look far to realize that the discourse on the subject has been accompanied, in the field of psychological practice, by a process of depoliticization of these same practices. In the same movement in which the subject is taken as the center (or even possibly off-center), a social dichotomy operates with what is believed to go around it.

Two realities (internal/external) are in constant articulation, but always two realities to be regarded with their given specific analytical tools. This operation is not without consequences, and one of them has been, precisely, to keep two separate records: the subject/individual (Benevides, R, 2002) and the social, the desire and Politics (Guattari & Rolnik, 1986).

So it is not surprising that, among many, there is the claim that psychology and politics do not mix, or that when we are activists, we are not psychologists, and when we are psychologists, we should not be activists.

The paradigm that is guiding these statements is that science and politics are two separate spheres and that psychological practice, to take charge of the subject, should not deal with political issues.

The Depoliticization of Psychology

Such asceticism, desired by many and, as stated by many others, reached, has consistently placed desire as something on the order of the individual or as a matter of politics as the subject and the social order, or as a matter of the collective. The effect—depoliticization—in this type of analysis is striking, given that psychological practices are to deal with abstract subjects, abstracted/alienated from their context, and make their existential expressions as products/data to be recognized a priori universal. Depoliticization means to mark the place outside, separately, that policy in its various forms is released when it comes to the analysis of subjective questions. However, it would be more correct to say that there is also the production of a certain policy: one that puts on one side the macro and the policy, and on the other, the micro; on the one hand, the Unified Health System as the State’s duty and right of citizens, as guaranteed by the law of conquest, by the Constitution, and on the other, the production processes of subjectivity. Here, it seems, there is an important clue to follow because it is from the founding of psychology in these dichotomies that the individual is separated from the social, the clinic was separated from politics, the health care of people separated from care with the health of populations, the clinic was separated from public health, that psychology was put on the sidelines of a debate on the SUS.

Redefining the Interface of Psychology and the SUS

The question, then, insists: what are the interfaces of psychology as a field of knowledge and, more precisely, of psychologists as workers with the Health System? More than being a discussion of curriculum content, or even indicating subjects to be included and/or excluded from the training courses, we should ask ourselves about the practical, ethical, and political commitments that these psychologists have made and have taken as a priority in their actions. Of course, this does not separate the theoretical and conceptual support to these practices, and it is also clear that this is a statement of position, attitude, as to what is defined as an object and intervention field of psychology. It is then a discussion of ethics, or rather, ethical and political. If we do not accept the positions abstract, transcendent, detached from where life is happening, we immediately bring to the debate on contemporary issues, both in its transnational dimension, global and local, Brazilian.

Key Questions for Psychologists in the Age of Global Capitalism

To follow this path, we cannot avoid, therefore, other questions:

What will the new era of capital reserve for psychologists as their professional task?
Is it possible and/or desirable to continue the search for an identity for the psychologist, defined from an education grounded in the dichotomy between subjective and political?
How to break with the tradition of a psychology whose history, dating from the late nineteenth century, attaches to either a goal-positivist perspective, sometimes the internal-subjective perspective, keeping, in any case, the separation of records exclusive, the spheres individual, group, social?
How to think about the practices of psychologists also classified in areas of performance that are defined by the separation and, often, by disqualification from each other: school, community, clinic, work, legal?
How to think the formation of the Psychologist in a time of the trivialization of social injustice? (Dejours, 1999)⁴
What is proposed as guidelines to support an ethical position that is not abstracted from its political commitments?
How to think about the role of psychologists or the contributions of psychology if we do not include the world we live in, the country we inhabit?
How to think of a psychology that does not take as its object abstract subjects?
How to strengthen professional practice that is jointly responsible with the health of each and the health of all without separating them?

The Interplay of Clinical Practice, Subjectivity, and Politics

We must, therefore, address the question of the links between contemporary capitalism, clinical practice, and the production of subjectivity. This forces us to discuss the plan of the clinic in its inseparability of philosophy, art, science, and especially politics. And what highlights the clinical interface-policy? Because then we met with modes of production, modes of subjectivity and no more subject, mode of trial/construction and no further interpretation of reality, ways of establishing itself and the world that cannot perform its function in autopoietic⁵ without constant risk of crisis experience. What we mean is that defining the clinic in its relationship with the production processes of subjectivity necessarily involves risking ourselves an experience of critique/analysis of institutionalized forms, which commits us politically.

The subjective form, the subject, is a product resulting from the operation of production that is unfinished, is heterogenetic, never having exhausted the total potential energy of creation of forms. That’s why we say that subjectivity is plural, polyphonic, with no dominant instance of determination.

What matters most here is to highlight this aspect of the production of the subject, of an autonomous subject (Eirado & Passos, 2004) and, even more, which historically has been giving the effect of modulations of capitalism, namely the separation between production and product and, therefore, between the subjective process and subject. This separation has the consequence of the capture of reality in a given form, taken as natural, but it must be understood as a symptom—⁶to be placed under review. The symptom is presented in two dimensions: shape and strength. His face set, face-shape, is one that is seen trapped in the circuit closed on repeating itself. The job analysis should focus on this circuit in order to produce detours that force him to repeat the operation. The analytical difference frequent in clinical interventions is nothing but the destabilization of these forms, allowing the appearance of the forces of production from which that reality is formed.

The Clinical Experience: A Return to the Collective

Here we could articulate what we understand the clinical experience as the return of the subject to the terms of subjectivity, the plan is that the production plan of the collective. The collective, here, of course, cannot be reduced to a sum of individuals or the result of a contract that individuals make with each other. Collective regarding this production plan, composed of disparate elements and experimenting all the time, differentiation. The collective is the crowd, the composition potentially unlimited beings taken in the proliferation of forces. In the collective, there is, therefore, no private property, personal, anything that is private, since all forces are available to be experienced. This is where we believe if given the experience of the clinic: experimentation on the collective, public trial.

Ethical Principles for Psychology’s Engagement with the SUS

The track that followed, which indicated that the foundation of psychology is founded in the separation of macro and micro, opens up, then, to some detours as ethical principles that I believe can contribute to the debate about the interface of psychology with SUS:

Principle of Inseparability	If we take psychology as a field of knowledge devoted to the study of subjectivity, and if this is understood as a collective process of production resulting in forms that are heterogenetic and always unfinished, it is impossible to separate, although there are distinctions, the clinical from the policy, the individual from the social, the collective from the singular, the ways of caring from the ways to manage, the macro from the micro. Making public policy—and the NHS is fundamentally a public policy, because it is for anyone—is to take this dimension of collective experience as the one generating the individual cases. In this sense, thinking about the interface of psychology with the SUS will be exactly this connector point: the subjective processes take place in a collective plan, a plan of multiplicities, the public plan. SUS, while winning the Brazilian people, of humanity, is made as public health policy.
Principle of Autonomy and Co-Responsibility	Thus, it is also impossible to think of psychologists in practice who are not readily compromised with the world, with the country that we live in, with the living conditions of the Brazilian population, with the engagement in the production of health (Campos, 2000), involving the production of autonomous individuals, actors, co-participants, and co-responsible for their lives. Here, the interface of psychology with SUS is given by the certainty that the process of inventing itself immediately is the invention of the world and vice versa.
Principle of Transversality	Psychology, like any other field of knowledge/power, does not explain anything. It is itself to be explained, and this only gives a ratio of intercession with other knowledge/power/disciplines. It is in between the knowledge that the invention occurs; it is at the limit of their powers that have the knowledge to contribute to another possible world, for another possible health.

The contribution of psychology in the SHS can be precisely at the intersection of these three principles.

From Principles to Action: Creating Devices for Change

But it is, especially, in a certain method, in a certain mode of operation, that we believe can be our greatest contribution and also our biggest challenge. It does not help those principles if they are not just political action, action on the polis, action on the formation processes of the city and subject. What we want to emphasize is that the axes of universality, fairness, and completeness, the SUS constituting, only become effective when we can invent ways to make things happen such axes. Interests and ask how to do here, our experience indicates that the construction of networks, group, device co-management, increased rates of transversality, investing in projects that increase the degree of democracy and institutional participation, are some of the routes to be followed.

Experiences in Implementing Humanization and Health Promotion Policies

In our recent, and has just ended, experience in the Executive Secretariat (SE) of the Ministry of Health (MOH) (www.saude.gov.br)⁷, coordinating the National Policy of Humanization and the National Policy for Health Promotion, we were ahead the challenge of building public policies that were committed to the principles enunciated above. Being in the state machine in a contemporary capitalism that naturalizes neoglobaliberal imposed, all the time, movements of resistance to what was presented as inexorable: programs, projects, departments, and work processes fragmented, separate systems of care and management of health.

Moreover, the challenge was placed on exercising with workers and managers of MS itself just another way to build public policy. We did not want, in fact, just another government policy. We wanted to move in another direction of our way of doing and, therefore, we do not just enough to agree with the axes of the SUS: universality, comprehensiveness, equity. Dare we needed to establish the state machine, production policies of autonomy and social emancipation. We needed to resize health policies in such a way as to create spaces of gestation, dissemination, and contamination of new societal and civilizational alternative (see Axis 1 of the WSF in www.forumsocial.org). We thought to give other directions for their own Executive Secretary of the MS that previously only ran the policies formulated by other Departments. We needed to effect the co-management, agree with what we said, co-formulating policies and not just playing silly spaces dispute territories of knowledge/power. We invest in cross-cutting policies and not separated care/management/training and social participation. We believe, finally, another way of thinking and doing politics.

Creating Spaces for Dialogue and Collaboration

Think-how health policy requires, therefore, creation of devices requires the creation of spaces for contracting between various actors in health networks, requires a being with the other—user, employee, manager. Here certainly Psychology can be, here she can make intercession. We insist, is not enough distance to formulate, regulate, control policies, we must create ways to create devices (Benevides, R, 1997) devices⁸, which give support to these policies on the set of conflicts of interests, desires, and needs of all these actors.

The direction taken since late 2004 in uneasy in that MS decides, among other measures, changing the profile of SE shifting to horizontal policies such other Departments.

Inseparability of Care and Management

Experience in coordinating these policies imposed on us in MS, then a modulation of what we said already before. If we talked before the inseparability between the clinical and policy (see Steps & Benevides, 2004), we can now say the inseparability of modes of address, to care and ways to manage, inseparability of care and management, therefore. There is a path to be mapped, traveled, made up, if we wish, we too, psychologists, allied to the resistance movements who bet on the construction of another possible world.

Joining the Movement for a More Just and Equitable Health System

Finally, it is worth remembering that SUS is born as a movement, known as Health Reform, together with other social movements in the struggle against military dictatorship and for democracy, guarantee human rights. We were in the years 1970/80, which is also organized at the international level the huge wave of neoliberalism. SUS was undoubtedly during these years, the movement established itself as resistance to privatization of health. Resist the privatization of health, life is a task for many is a task for us all. It behooves us, psychologists, decide that we allied movement, which invented motion, which we intercessions between Psychology and SUS, between psychology and public policy.

gy and public policy.