Anderson Paiva, 41, had a quiet childhood while living in Tocantins, where he was born. But when he was a teenager, his father separated from his mother and, from then on, he did not help the family anymore. The son did not handle the breakup well and began to disobey his mother, Vera Lícia dos Santos, 60.
Mother and son no longer live there. Years ago, they settled in Goiás. It was in the capital of that state that Anderson, shortly after coming of age, carried out an armed robbery and was arrested. At the time, he had a partner and a child.
For a while, his companion visited him in prison. But that didn’t last long as she broke off the relationship. He developed depression. “I was trapped there, very distressed, sad, without company. I felt lonely. You know what I did? Drugs. I used it every day”, remembers Anderson.
His mental health deteriorated further, until he reached a state of schizophrenia. Meanwhile, he remained imprisoned and without access to adequate mental treatment. His lawyer then obtained a measure to include him in the Paili (Integral Care Program for Crazy Offenders). Accepted on the project, about two years ago he left prison.
The Goiás program began to be thought of in mid-1996 and left the drawing board in 2006. Linked to the State Department of Health, it assists people in a security measure – when someone commits a crime, but is considered not responsible, that is, they cannot be held accountable for their actions. In addition, it receives those who presented mental suffering while serving their sentence, like Anderson.
With 355 patients currently assisted, Paili focuses on outpatient mental health care for patients, such as monitoring them in Caps (Psychosocial Care Centers). In cases of crises, the people assisted may be hospitalized in psychiatric beds until their stabilization. Afterwards, they tend to return to outpatient follow-up. The adoption of medication is also a possibility.
This model means that there are no judicial asylums in Goiás. The Federal District, Acre, Maranhão, Mato Grosso, Mato Grosso do Sul, Roraima and Tocantins also lack custody hospitals.
The other states must close their custody hospitals by May of next year, according to a resolution by the CNJ (National Council of Justice). As of this Tuesday (15), institutions can no longer receive new patients.
In Goiás, when a judge establishes the security measure, the process is sent to Paili. At the organ, the case is forwarded to a program technician who tries to locate the patient and his family. It is common for this data to be attached to the process, but sometimes it is difficult to build the initial contact.
Hélia Crispim, the program’s psychologist, gives a recent example. She received the file from a patient under security measure who lived in the interior of the state and decided to visit him. Upon arriving at the patient’s home, she was faced with a situation of extreme social vulnerability. “It’s someone with schizophrenia who has the support of Caps, of neighbors, but without family.”
With difficulty, she located part of his family in Bahia. She made contact with a nephew of the patient and, when explaining the condition, discovered that the relatives thought he had disappeared. In response, the nephew said that he would consult with the rest of the family in order to understand how they could help his uncle.
Family support, according to the psychologist, is a key to the success of the psychological treatment proposed by Paili. Patients who present better results usually rely on this support network. But sometimes it is difficult to convince the relatives of the person under security measures — among the crimes committed there are homicides or attempted homicides within the family nucleus.
There are also cases in which, even with this support, the patient does not adhere to the program. Celma Martins, coordinator of Paili, mentions that of a woman with schizophrenia who started treatment several times, takes her medication, stabilizes her condition, but gives up everything to consume drugs and live on the streets. “When she sees that the situation is very angry, she goes back home and to the Caps, but there’s no way around it, she doesn’t stabilize the situation.”
A strong network of health care institutions, such as a wide supply of Caps, is also a requirement for a positive follow-up result. Data from the Ministry of Health for 2022 indicate that there are 81 Caps in Goiás. Paili works mainly with these mental health centers, responsible for patient care. “We start to articulate with the Caps how the reception will be to start the treatment”, explains Celma.
One of the Caps is Bem-Me-Quer, in Aparecida de Goiânia, a city close to the capital. The unit’s coordinator, Marta Paulina, says that receiving a patient from the Paili is the same as someone who is not in the program. As usual, the person is integrated into therapeutic groups, workshops and medical care.
In cases of crisis, it may be necessary to stabilize the patient in other health centers and, after that, he can be admitted to the Caps night beds. There is also the possibility of the person staying during the day at the institution, until they return to the pattern of weekly therapeutic groups.
The only difference between a regular Caps patient and a Paili patient is the sending of reports. That’s because the program periodically forwards an update on the person under security measure to the judge who ordered it. To prepare these documents, the technicians at Paili consult the family and the Caps responsible for the patient.
In addition to Caps, therapeutic residences are used when the family does not support the patient. The problem is the lack of these spaces.
“We have users with enormous difficulty in making a new adhesion to the family, to the territory, because was hospitalized or imprisoned for a long time, and we would need [mais] therapeutic residences for that”, says Nathália dos Santos Silva, manager of mental health at the State Department of Health.
She says that it is also important to increase the amount of Caps with night or 24-hour care to assist patients in cases of crisis. However, this type of center is only suitable for cities with more than 150,000 inhabitants — Silva claims that most municipalities in the state have less than 15,000.
Another necessary improvement is the availability of beds for mental health in general hospitals. Currently, in Goiás, there are only co-financed beds in psychiatric hospitals associated with the SUS, but the idea would be to have them in general hospitals to improve care for these patients.
On the other hand, there are criticisms of the total closure of judicial asylums.
Medical entities, such as the CFM (Conselho Federal de Medicina) and the ABP (Associação Brasileira de Psiquiatria), wrote a letter in which they criticized the decision of the CNJ and pointed out that the removal of people under security measures from hospitals in custody represents a danger for public safety in the country. Another criticism made is that the public health system would not be prepared for the change.
In Paili, it is known that intercurrences may occur during treatment. Whenever one happens, such as a new crime committed by the patient or an unannounced trip, the technicians inform the judge responsible for the process. Even so, the cases are few. The recidivism rate among program participants is around 5%.