Challenges for Social Work in the Field of Mental Health in Uruguay

Introduction

This article reflects on the challenges currently faced by the Social Work profession in the field of mental health in Uruguay. These challenges emerge within a particular historical context, as Uruguay has been undergoing a reform process in the health sector for the past two decades. This process has been characterized by transformations in the model of care, as well as changes in the underlying conceptions and orientations of social policy in this field.

As documented in the national literature, the emergence and professionalization of Social Work in Uruguay were closely associated with the health sector (Ortega, 2008, 2011; Ortega & Beltrán, 2014). This historical trajectory illustrates, among other aspects, the profession's close relationship with the field of health and the structural determinants that continue to shape its professional roles and functions.

More specifically, this article focuses on the challenges faced by Social Work within the field of mental health. For at least four decades, the predominance of a model of care based on isolation, prolonged hospitalization, and the central role of the psychiatric hospital has been increasingly questioned in Uruguay (Amarante & Techera, 2025; Baroni, 2016; Techera & Borges, 2018). The enactment of Law No. 19.529 in 2017 formally established a framework for transformation aimed at the gradual closure of asylum institutions and monovalent psychiatric institutions, originally scheduled for completion by 2025, together with the development of a network of alternative community-based services. However, the implementation of this reform has faced persistent challenges related to the effective availability of resources, institutional coordination, the development of residential and community-based alternatives, and the conditions required to sustain discharge processes in everyday life (Silva, de Pena, Batalla, & Pedra, 2019; De León, de Pena, & Silva, 2020; Suárez, 2025).

Recent studies (Dutruel, 2019; Benítez, 2021; Zabala, 2018) have shown that, within professional practice, Social Work had already been developing interventions related to community-based services, discharge processes, and mental health promotion long before the reform process became institutionally established. In light of these developments, the following sections present and discuss the conditions brought about by the reform for the Social Work profession, together with the technical, ethical, and political challenges arising from the current context.

Social Work in the Context of Health Reform

As noted above, the relationship between Social Work and the health sector in Uruguay dates back to the origins of the profession in the early twentieth century. It was during the country's national modernization project that the visitadoras sociales (social visitors) played a fundamental role in administering social assistance, primarily within the healthcare sector. In a society deeply shaped by processes of medicalization (Barrán, 1995), the profession emerged closely linked to the field of health, performing public health surveillance functions within the framework of hygienist public health strategies.(Ortega, 2008, 2011; Ortega & Beltrán, 2014). More specifically, the incorporation of Social Work into the field of mental health dates back to the 1930s, and its role consisted primarily of family work related to mental hygiene (Vázquez-Valencia, 2016).

As the profession achieved greater institutional and academic recognition (Ortega, 2011), its professional autonomy increased (Freidson, 1978), and Social Work gradually became integrated into multidisciplinary teams engaged in both clinical and community-based practice.

Mental health policy in Uruguay has traditionally been oriented toward assistance-based practices centered on hospital care as the primary setting for treatment. The gradual shift toward a community-oriented model of mental health, emphasizing prevention and community-based care, began during the second half of the twentieth century. Major milestones in this process include the National Mental Health Plan of 1986, the recent Mental Health Law (Uruguay, Law No. 19.529, 2017), and the National Mental Health Plan 2020–2027.

Law No. 19.529 establishes, as its central objective, a paradigm shift toward community-based care grounded in a human rights approach, comprehensive mental healthcare, and community-based psychosocial rehabilitation approaches.

Within this new legal framework, hospital discharge processes and the closure of monovalent psychiatric institutions, originally scheduled for completion by 2025, have become central components of the mental health reform process. The debate surrounding the extension of this deadline until 2029 reflects the complexity of a reform that requires transforming professional practices, institutions, resources, and the social organization of care. The public relevance of this issue is closely linked to the prominence of mental health on the national policy agenda. Reform of the mental healthcare system, the closure of psychiatric asylums, the development of community- based services, and the living conditions of people discharged from psychiatric institutions continue to be the subject of political, technical, social, and academic debate.

These discussions encompass not only the organization of health services but also broader questions concerning citizenship, human rights, social inclusion, autonomy, care, state responsibility, and the material conditions necessary for community living. One of the public debates revolves around how the process of deinstitutionalization, as established in Article 37 of the law, should unfold. In this regard, some advocate for the definitive replacement of the asylum model with a community-based network of care, support, and territorial services, whereas others emphasize the difficulties of closing asylum institutions without sufficient resources, adequately trained teams, appropriate residential alternatives, and community networks capable of ensuring continuity of care. Concerns have also been raised by family members, professional teams, social organizations, and institutional actors regarding continuity of treatment, access to housing and income, the rebuilding of social relationships, and the prevention of readmissions.

Problems and Challenges for Social Work

Although only briefly outlined here, these are some of the key debates currently confronting Social Work in the field of mental health. These debates permeate the profession and continually challenge everyday professional practice, both in hospital settings and in community-based services. This demonstrates how the profession is situated within a particular historical, political, and social context, through a dialectical relationship that connects sociohistorical determinants with the concrete forms that professional intervention takes.

In this regard, Silva and Carballo (2023) describe the contradictory nature of mental health reform, arguing that the difficulties involved in its implementation are directly related to the very configuration of the mental health field and the overlap between discourses and decisions that remain disconnected from one another. They therefore call for research aimed at identifying the key problem areas that represent obstacles to the advancement of the reform. According to these authors, such obstacles operate along two interrelated dimensions: first, the legitimacy granted to particular actors to produce knowledge and shape mental health policy; and second, the configuration of an institutional and administrative apparatus that underpins this outlook on mental health, pointing directly to the place occupied by medico-psychiatric expertise.

At the level of discourse, there appears to be a relative consensus regarding the need to transform the prevailing model of care. However, persistent weaknesses in the coordination and governance of health policy mean that any attempt at change initiated by actors involved in the reform—including Social Work—will inevitably encounter obstacles to what is intended to be transformative practice. However, by positioning ourselves within certain institutional structures, we may create genuine opportunities to introduce into public discourse and social policy planning some of the actions that Social Work has already been developing prior to the implementation of Law No. 19.529.

Within this context, social workers are required to engage in continuous dialogue and coordination across the various institutions and agencies involved in mental health, acting as a bridge between the healthcare system—which, on its own, cannot adequately address the full range of emerging mental health needs—other areas of social policy, and the concrete needs of individuals. In this regard, intersectoral collaboration plays a central role in discharge processes and making it one of the profession's key areas of professional contribution.

With regard to the discharge process, it constitutes a privileged space in which the non-neutral nature of professional intervention comes into play, while also bringing structural inequalities related to housing, food security, and access to care into focus. This continually challenges the profession in its role as guarantor of human rights and of the continuity of the right to health beyond hospitalization. Yet, in everyday professional practice, these rights cannot currently be fully guaranteed.

Within institutional settings where medical expertise continues to predominate, placing the social dimensions of mental health on the policy agenda remains one of the profession's greatest challenges. In this field, professional practice is constantly being questioned and negotiated, ultimately oscillating between two models: the hegemonic biomedical model, centered on hospital- based care, and the community-based model, focused on prevention and health promotion.

With regard to the conditions under which professional practice is carried out, those working in care and hospital-based settings are often required to respond immediately to issues that hinder continuity of care following discharge, while also addressing the social dimensions of suffering from a preventive perspective.

Finally, in light of the issues discussed above, a weak relationship can be observed between Social Work and the social and family organizations that have long advocated for the effective realization of rights in the field of mental health. This weakness may be explained by the profession's strong institutional location within state services and by the demands placed upon practitioners in these settings, which, as previously noted, are primarily assistance-oriented and driven by institutional urgencies. Once again, the contradictory nature of professional practice becomes evident in the persistence of two distinct approaches to mental healthcare.

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