Mental Health, Care, and Illness Politics: Lessons from the Brazilian Anti-Asylum Struggle

By Caio Maximino

Volume 27, no. 3, Public Health

Global mental health statistics reveal a pervasive crisis, with an estimated 14 percent of the world’s population living with a mental disorder.¹ In many countries this occurs in the context of neoliberal capitalism, which produces privatizing policies that transfer the burden of caregiving back to families, producing a crisis of care.² This shift is partly a legacy of deinstitutionalization in the Global North, which saw the closure of asylums without the provision of adequate alternatives. As Andrew Scull notes, deinstitutionalization withdraws state responsibility and places greater responsibility for care on communities; consequently, many patients end up in prisons, on the streets, or in poorly regulated private facilities.³ This dynamic exemplifies what Beatrice Adler-Bolton and Artie Vierkant term extractive abandonment: under capitalism, surplus populations deemed unable to participate in value production are abandoned by both the state and capital, while still remaining a source of profit through industries built on their supervision, treatment, and confinement.⁴

This pattern, however, is not universal. In some instances, deinstitutionalization movements were intertwined with anti-capitalist critique and the construction of community-based alternatives. Italy and Brazil stand as pivotal examples. Focusing upon this latter case, this article explores the questions that emerge: How can the history of the Brazilian anti-asylum struggle inspire models of deinstitutionalization that avoid extractive abandonment, and how can the radicalism of workers’ and patients’ movements continue to shape this struggle?

The Brazilian Luta Antimanicomial

As documented by Paulo Amarante, the Brazilian anti-asylum struggle, Luta Antimanicomial, emerged in the late 1970s as a response to a crisis within the National Mental Health Division (Divisão Nacional de Saúde Mental, DINSAM) while the country was under a brutal military dictatorship that lasted from 1964 to 1985.⁵ The crisis ignited in 1978 when three doctors denounced irregularities, mistreatment, and violence at the Pedro II Psychiatric Center. Although these denunciations were not explicitly political, they were interpreted as subversive by the regime, resulting in the doctors’ removal and the subsequent dismissal of the 263 professionals who stood in solidarity with them. In response, the Mental Health Workers’ Movement (Movimento dos Trabalhadores de Saúde Mental, MTSM) emerged as a noninstitutional space for activism, uniting healthcare workers and professional associations in the transformation of psychiatric care.⁶

The MTSM quickly expanded its scope, gathering in critical discussions and professional meetings on mental health, and eventually adopting broader political demands including amnesty for political prisoners and opposition to the privatization of healthcare. Crucially, it began critiquing the psychiatrization of society and challenging the dominant biomedical model in dialogue with international figures like Franco Basaglia, Felix Guattari, and Erving Goffman. The movement sought to understand how mental disorders are intertwined with social problems, healthcare policy structures, and the precarious conditions of workers. This analysis exposed a system of “extractive abandonment,” also termed the “commodification of madness” by Amarante.⁷

The 1980s marked a shift as Brazil’s political conjuncture increasingly demanded an end to dictatorship. The MTSM adopted dual strategies: an “instituting” trend, in which members took positions within the state to steer policy toward a public health model that framed health as a citizenship right; and  a “unionizing” trend, in which members acted as employees to fight for better working conditions and hold the state accountable. While effective, these strategies risked becoming technocratic or reformist.⁸

The movement’s true turning point came in 1987 at the second MTSM Congress (Congresso de Bauru), in which the movement was renamed Luta Antimanicomial. This marked a radical rupture: the movement was no longer limited to mental health workers and included service users, their families, and activists from other social movements. The movement’s Bauru Manifesto explicitly linked the asylum to broader structures of oppression, stating: “The asylum is the expression of a structure present in the various mechanisms of oppression… in factories, in juvenile institutions, in prisons, the discrimination against black people, homosexuals, Indigenous people, women.”⁹ This alliance forged a powerful political praxis, transforming the struggle from a narrow workers’ fight into a transversal social movement.

This period saw rapid deinstitutionalization and the creation of new care modalities, most notably the Centers for Psychosocial Care (CAPS). These community-based centers operate with multidisciplinary teams, prioritizing psychosocial support over an exclusive focus on drug therapy. The movement also forged alliances with service user and family associations, leading to cultural actions like parties and political events that rebuilt social bonds and community for people isolated within asylums.

In 1989, building on the movement’s momentum, the 3.567 Bill (Lei Paulo Delgado) was proposed, aiming to regulate patient rights and phase out mental hospitals in favor of community-based care. In 2001, after years of advocacy, this bill was finally passed as Law n. 10.216, the Psychiatric Reformation Law.¹⁰ This legislation consolidated the movement’s gains on the creation of new care structures and models as well as in lawmaking, initiating the dismantling of asylums and their substitution with a community-based network. This network was later expanded (2011-2013) into the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS), which integrated primary care, strategic psychosocial care (CAPS), urgent care, transitional housing, and recovery-based programs like solidarity cooperatives.

One important theoretical and technical contribution of this system was the notion of an “expanded clinic” (Clínica Ampliada), a strategy of creating collaboration between workers from different fields. From healthcare to social work, these expanded clinics promoted broader conceptions of the health–disease process as the entanglement of biological, social, and psychological factors that appear in the lived experiences of patients.¹¹ In order to acknowledge these factors, this strategy prioritizes mental healthcare alliances between service users and an interdisciplinary team, co-constructing diagnostic hypotheses and therapeutic processes. This practice reconceptualizes the “working object” as more than a fragmented individual who is a reflection of their symptoms, social conditions, or affective situation.

Another theoretical contribution of expanded clinics is the broader notion of territory as a system of objects and actions that acts as an interface between the political and the cultural—providing “a space for symbolic construction and belonging, linking ethological, subjective, sociological, and geographic meanings.”¹² With this new understanding, the movement posited that individuals should be referred back to the territory—that is, not to the area of catchment of a specific service, but to the lived space that is shared with others. Reinsertion in the territory requires providing service users with tools that allow them to return to the world of social exchanges. This also means understanding territory itself as a site of struggle for the basic rights of housing, productive coexistence, nutrition, and sociability for all.

By working with the theoretical and practical frameworks of the “expanded clinic,” the movement effectively reduced nationwide mental healthcare costs and long-term hospitalizations.[/note]Bruna Lopes Resende et al., “Nationwide Decline in Psychiatric Hospitalizations and Costs in Brazil, 2008–2022: A Retrospective Descriptive Study Evidencing Reform-Driven Community Mental Health Gains,” The Lancet Regional Health – Americas 56 (2026), https://doi.org/10.1016/j.lana.2026.101425.[/note] That said, implementation remains uneven, funding insufficient, and a political counter-reformation has threatened these gains since the mid-2010s, underscoring the need to further radicalize the struggle.¹³

Luta Antimanicomial and Grassroots Movements

The Brazilian movement’s extraordinary gains were not limited to policy but extended to the creation of new social places for madness. This was driven by its foundational alliance with service users, a dynamic mirrored in parallel global movements where people labeled as mentally ill organized to reclaim authority over their own experiences.

From the radical militancy of Germany’s Sozialistisches Patientenkollektiv (SPK), which declared illness a product of capitalist exploitation, to the United Kingdom’s Mental Patients’ Union, which challenged forced treatment, these movements transformed silenced subjects into collective political agents.¹⁴ Their core insight was to call out psychiatric labeling and coercion as unneutral medical interventions and technologies of social control that enforce conformity to capitalist norms, racial hierarchies, and gendered expectations. By centering lived experience as a legitimate epistemological ground, these movements reject the paternalistic premise that care must be imposed from above, insisting that healing is inseparable from the struggles for both autonomy and community.

The radicalization of mental healthcare begins with the fundamental refusal of treating psychiatry as a depoliticized institution. Psychiatry survivors articulate that what is pathologized as individual illness is often a rational response to systemic oppression—poverty, racism, and the alienation of capitalist life. The Brazilian Luta Antimanicomial crystallized this critique into a powerful political praxis, demonstrating that the asylum was not merely a therapeutic failure but a central apparatus for disciplining those rendered disposable by a stratified social order. Converging these threads reveals that the fight against psychiatric coercion is inseparable from the fight against a system that demands conformity to conditions of chronic instability.

The Brazilian movement offers a strategic blueprint for this anticapitalist reimagining. Its architects understood that dismantling the asylum required simultaneously constructing a new social fabric founded on collectivity and mutual aid as true care, not as a commodity. The success in passing the Psychiatric Reformation Law was not an endpoint but a foundation for radical experimentation, creating CAPS and cooperative housing that operate as autonomous zones against the atomizing pressures of the market. For contemporary survivors’ movements, this demonstrates that deinstitutionalization is a materialist project, since it understands that the abolition of the asylum necessitates the radical remodelling of social relations beyond the “humanization” of services. In fact, due to their role in the larger capitalist economy, these services are inherently dehumanizing.¹⁵ Thus, ensuring true care is not a matter of increasing users’ autonomy or demanding the abolition of isolated, violent facilities but a struggle for the redistribution of resources to maintain life-sustaining networks outside the logic of profit.

The Brazilian Luta Antimanicomial itself gained strength, power, and impact when it incorporated the active participation of service users as allies in the struggle.¹⁶ Through this alliance it became clear that mental health care required an expanded conception of health—one that includes an  understanding of users’ position within a capitalist system of value production and profit extraction as well as an understanding of the ways in which the field is traversed by forces and power relations that hinder service user inclusion. When allied with this emphasis on user protagonism, the elevation of lived experience as a political and epistemological foundation transforms mental healthcare from a top-down system of compliance into a horizontal struggle for autonomy. Radicalizing mental healthcare thus means prioritizing peer support and community accountability structures that divest power from capital and its clinical intermediaries, and recentering it within communities armed with an understanding of oppression as a structural condition that must be collectively overthrown.

Ultimately, the Luta Antimanicomial positions the horizon of mental healthcare as a site of struggle for a post-capitalist world. It reveals that the pervasive crisis in mental health is not a failure of medical intervention, but a logical outcome of the commodification of care, the destruction of social bonds, and extractive abandonment. To pursue anti-asylum politics is to pursue an anti-capitalist politics of care. This alliance calls attention to the intersecting forces that determine who is deemed sane, who is incarcerated, and who is mourned. By joining the survivor-led demand for epistemic justice with the Brazilian movement’s legacy of militant community building, we move toward a vision of mental healthcare not as a system of management, but as a site of liberation—a collective project of healing tethered to our shared freedom from exploitation and oppression.

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Caio Maximino, PhD is a professor at Universidade Federal do Sul e Sudeste do Pará, a peripheral university at the heart of what used to be the Amazon. There, he researches the neuroscience of mental health, as well as the neurobiology of cooperation and social behavior. @caio_maximino

Notes

1. World Health Organization, World Mental Health Today: Latest Data (World Health Organization, 2025), https://www.who.int/publications/i/item/9789240113817.
2. Premilla Nadasen, Care: The Highest Stage of Capitalism (Haymarket Books, 2023).
3. Andrew Scull, Madness in Civilization: The Cultural History of Insanity (Thames and Hudson Ltd, 2015).
4. Beatrice Adler-Bolton and Artie Vierkant, Health Communism: A Surplus Manifesto (Verso, 2022).
5. Paulo Amarante, Madness and Social Change: Autobiography of the Brazilian Psychiatric Reform (Springer International Publishing AG, 2022).
6. Amarante, Madness and Social Change.
7. Adler-Bolton and Vierkant, Health Communism; Amarante, Madness and Social Change.
8. Amarante, Madness and Social Change.
9. National Mental Health Workers, “Manifesto de Bauru,” Manifesto, December 6, 1987, https://site.cfp.org.br/wp-content/uploads/2017/05/manifesto-de-bauru.pdf.
10. Delgado, “LEI Nº 10.216.”
11. Amarante, Madness and Social Change.
12. Juarez Pereira Furtado et al., “A concepção de território na Saúde Mental, ”Cadernos de Saúde Pública 32 (2016): 7, https://doi.org/10.1590/0102-311×00059116.
13. Pedro Henrique Antunes da Costa and Kíssila Teixeira Mendes, “Contribuição à Crítica Da Economia Política Da Contrarreforma Psiquiátrica Brasileira,” Argumentum 12, no. 2 (2020): 44–59, https://doi.org/10.18315/argumentum.v12i2.28943.
14. Sozialistisches Patientenkollektiv and Wolfgang Huber, “SPK – Turn Illness Into a Weapon: For Agitation by the Socialist Patients’ Collective at the University of Heidelberg” (KRRIM – PF – Verlag für Krankheit, 2023), https://www.spkpfh.de/SPK_Turn_illness_Contents.htm; Sasha Warren, Storming Bedlam: Madness, Utopia, and Revolt (Common Notions, 2024).
15. Sozialistisches Patientenkollektiv and Wolfgang Huber, SPK – Turn Illness Into a Weapon; Warren, Storming Bedlam; Adler-Bolton and Vierkant, Health Communism; Amarante, Madness and Social Change.
16. Amarante, Madness and Social Change.