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Diplomatura de Políticas Públicas en Salud Mental 2026 — Transcript

by Escuela de Gobierno en Salud "Floreal Ferrara" · 11,385 words · 1,848 segments · language en · Watch on YouTube

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0:09Hello, good day. How are you all?
0:11Welcome to this next meeting of the
0:14diploma program. We are in module five,
0:17on problematic consumption, policies,
0:19institutions, and approaches. Meeting
0:23four. In this case, we will have block
0:26one, which you have in the program
0:29corresponding to Rosy; you will find it
0:31uploaded later on the virtual platform
0:34for you to watch. So, let's move on to
0:37block two, which starts now. And for
0:41this, we welcome two instructors whom
0:42we, of course, thank for their
0:44participation today. Mercedes Copelotti
0:48is a specialist in adult clinical
0:49psychology and executive director of
0:51the Reencuentro Specialized Hospital
0:53for Mental Health and Problematic
0:55Consumption in La Plata. She has had a
0:58hospital career from 2010 to 2026 at
1:00the San Martín Hospital in La Plata.
1:04She has participated in residencies,
1:06worked as a staff psychologist, head of
1:09the mental health service, director of
1:11health networks for the UNLP Mental
1:13Health Pro-Secretariat since 2025, and
1:16has experience in university teaching,
1:18research, and outreach at the Faculty
1:20of Psychology of the National
1:22University of La Plata. We also have
1:27instructor and psychologist Lucila
1:29Romero, head of the mental health
1:31service at the San Martín General
1:34Hospital in La Plata and former
1:36interdisciplinary teaching coordinator
1:39for mental health residencies. So,
1:42welcome. The floor is yours to begin
1:45whenever you like.
1:50Hi, how are you? Good day. How's it
1:52going? We have a PowerPoint that I
1:56understand the team will start showing
1:59to accompany the presentation. of the
2:05class. I will introduce myself briefly
2:09once again. My name is Mercedes
2:11Copelotti, I am a psychologist. I did
2:14my residency at the San Martín
2:16Hospital in La Plata, then stayed on as
2:18a staff psychologist, and for the last
2:205 years, I was the head of the mental
2:23health service at that hospital. It is
2:25an interzonal hospital, a reference for
2:28the province. It is a hospital that has
2:30an emergency room, inpatient wards, a
2:35day hospital, and outpatient clinics as
2:38well. So, from that perspective, in
2:45principle, I have the most clinical
2:48practice, in the same way as Lucila,
2:51who is here with me and will surely
2:54introduce herself later, but just so
2:57you know where we are speaking from. It
3:03is all the clinical experience related
3:07to what we have had at that hospital.
3:12Since this year, since April of this
3:13year, I have been the executive
3:15director of the Reencuentro Hospital in
3:17La Plata, which is a hospital
3:18specializing in mental health and
3:20problematic substance use. So, from
3:23that perspective, I will also be able
3:25to tell you something and contribute a
3:28few points for us to think about
3:30together. Well, the part I wanted to
3:34share with you, I organized around two
3:38aspects: some introductory issues
3:42regarding the approach to problematic
3:45substance use, just to frame the
3:49presentation in general and where we
3:52are speaking from. And then, I am going
3:58to share the results of research from a
4:02fellowship that we carried out in
4:052024-2025 regarding hospitalizations
4:08for problematic substance use. Yes.
4:13Well, Initially, what it implies when
4:21we place the issue of addiction as part
4:26of mental health is a necessary floor
4:31from which we must start, right? As you
4:38know, Article 4 of the Mental Health
4:41Law locates addictions, stating that
4:44they must be addressed as an integral
4:46part of mental health, and that people
4:49with problematic drug use have all the
4:52rights and guarantees established in
4:55that same law. Yes. And I place this as
5:01a starting point because it implies,
5:04initially or mainly, two consequences.
5:10First of all, because it excludes
5:12consumption from the immediate
5:15association with the realm of crime and
5:17social disorder, right? That is, it
5:21breaks the equivalence of addict with
5:24criminal or someone who breaks social
5:26law. Yes. To the extent that it puts
5:30the focus on people with problematic
5:32drug use and their rights. Yes, you
5:36know that the whole law is shifting the
5:39axis away from what is social order, it
5:41shifts the focus of social order, right
5:44? I mean, from preserving social order
5:49as the main priority for a law to
5:52guaranteeing the rights of individuals
5:56as the priority. Yes, in the same way
5:59as when we talk about certain and
6:01imminent risk—which we will get into
6:02in a moment—and not about
6:04dangerousness, right? It situates that
6:08same shift; when, in the previous
6:11paradigm, dangerousness was central to
6:14intervention, it was dangerousness in
6:18relation to others. A person was
6:22considered dangerous to a certain
6:24social order, right? To others. When we
6:27talk about risk, the accent is placed
6:29on the person who is suffering. Yes? In
6:33the same way, placing addictions in the
6:36field of mental health implies that
6:38shift. Yes? And secondly, uh, I would
6:43emphasize that this implies including,
6:46uh, the approach to problematic
6:49substance use within mental health
6:51services in general hospitals. Yes. Uh,
6:56you know that, uh, historically, mental
6:59health services in general hospitals
7:02used to refer patients to specialized
7:04services, right? To specialized
7:09institutions. for, uh, addressing
7:12substance use, right? This was done for
7:14so long. When we started our residency,
7:18uh, I started in 2010, in 2009, it was
7:21common practice for someone who
7:24consulted and, uh, mentioned they were
7:27using substances. So, it was a person
7:31who was referred directly to a
7:33specialized institution; it was not
7:35considered, uh, appropriate to address
7:39it within the mental health service. Uh
7:41, starting with the Mental Health Law,
7:44what is established is that, I mean, by
7:47placing, I insist, problematic
7:49substance use as part of mental health
7:52in general, then, uh, it establishes
7:55the need for it to be addressed as part
7:58of general mental health. precisely, uh
8:03, now that doesn't necessarily mean, or
8:08we can discuss it, uh, that it doesn't
8:11require a somewhat specific approach;
8:14uh, it doesn't necessarily, uh, let's
8:17say, by having it in a general hospital
8:21mental health service, it doesn't mean,
8:24uh, the approach is exactly the same,
8:27right? Just as other conditions also
8:30require a certain level of specificity.
8:33I insist, it is a point, uh, to be
8:35discussed. A in the case of Reencuentro
8:42Hospital, for example, the process was
8:44the other way around. In its origins,
8:46it exclusively treated addictions,
8:48right? And over time and following, uh,
8:51the National Mental Health Law, they
8:53began to address mental health issues
8:56in general. including problematic
9:00substance use, right? I mean, it's the
9:02opposite of what has happened in
9:04general hospitals, uh, uh, in a, uh,
9:08generalized way, right? A at the same
9:13time, however, Reencuentro Hospital
9:15maintains a post-basic residency in
9:17addictions, right? So, uh, I think this
9:21context raises the issue of specialty
9:24versus specificity in the approach,
9:26right? Uh, I don't know, it's a
9:30question, uh, for me: is it about
9:32training in general mental health and
9:34then in substance use issues, or how is
9:37one field linked to the other, right?
9:40Are they equivalent, do we overlap them
9:42, right? These are all questions that I
9:45think we shouldn't skip, but rather, uh
9:46, they require us to think about them
9:48based on what the clinical practice
9:49itself presents to us, right? Uh, the
9:53law presents a similar issue for us
9:55regarding hospitalizations in general
9:57hospitals, right? Regarding this matter
10:01of specialty and specificity, I mean,
10:03the law establishes that mental health
10:06hospitalizations must take place in
10:08general hospitals and no longer in
10:10specialized institutions like
10:12monovalent ones. Now, does this mean it
10:17doesn't suppose, doesn't require any
10:19specificity? Does it mean that people
10:22with mental health conditions have to
10:24be together with people with other
10:26issues, right? With issues of a
10:29different nature, do they necessarily
10:30have to be in a medical clinic ward,
10:32for example, in trauma, right? There
10:35are different interpretations regarding
10:37this subject. Not necessarily placing
10:40the person with a mental health
10:42condition—I mean, enabling
10:44hospitalizations in general hospitals
10:47—does not necessarily imply that it
10:49is the same, right, or that it doesn't
10:51require a certain specificity. It
10:54probably depends on the complexity of
10:58the cases in question, right? But well,
11:02these are all issues raised by the law
11:04that require work regarding how we
11:07interpret that, how we carry it out,
11:09and if it changes according to the
11:12complexity of the cases. Yes. The truth
11:19is that currently, the comprehensive
11:22care of people with problematic
11:24substance use represents quite a
11:27challenge for the health system, right?
11:32Because they have been increasing
11:34exponentially in quantity and
11:36complexity, which is why it is
11:37necessary to work on prioritizing some
11:40institutions that have experience in
11:42addressing substance use, and
11:43sustaining that reference, right?
11:47Without that implying exclusive care,
11:49right? Of substance use issues, nor
11:52that they be established as the only
11:54providers with the possibility of
11:55addressing the field of substance use.
11:58I think there is something there that
12:00needs to be worked on. I was telling
12:02you that I have been at the hospital
12:04for a few months now in the management.
12:07Well, there is something about that,
12:08right? What do we do with that history,
12:10with what we have, with the substance
12:11use experience we have? How do we do it
12:14within the paradigm of mental health
12:16and human rights? What form does that
12:19take? There is another point I
12:22mentioned in the introduction regarding
12:25the link between social determinants
12:27and problematic substance use, which I
12:30also think is necessary to highlight.
12:35We cannot think of mental health
12:38conditions in general as individual,
12:40right? We have considered that
12:44discussion settled for a long time,
12:47despite the fact that the insistence on
12:50returning to the individual, to the
12:53organic, etc., keeps coming back. E We
12:58cannot think of them outside the
13:00context in which they take place. We
13:04know that the mental health law defines
13:07mental health as a process, right?,
13:10determined by historical, socioeconomic
13:13, cultural, biological, and
13:15psychological components, right? And it
13:19places the preservation of those
13:22components in relation to the
13:24fulfillment of the human and social
13:27rights of people, right? And the law
13:32presents mental health in that way,
13:34right? And mental suffering in a
13:37similar way as well, right? In relation
13:42to the fact that it posits it as any
13:44type of psychic suffering, right?,of
13:47people, of human groups, and places it
13:49as a complex process also determined by
13:51multiple components, right? So, what I
13:55am interested in underlining is that
13:57mental health and suffering are
13:59situated as dynamic processes and not
14:01as permanent, right?,or invariable
14:03states. And that dynamic is articulated
14:07directly with the social context and
14:09the guarantee or violation of rights.
14:12Yes? That is something we also noted in
14:15the introduction regarding what we talk
14:17about when we speak of mental suffering
14:19and mental health and what relationship
14:21they have with the context and with
14:23what we can call social determinants,
14:25right? And I was saying this in the
14:29case of mental suffering in general.
14:32And in particular, it occurs in a way
14:34that we necessarily have to contemplate
14:37in the case of problematic substance
14:39use, right? Because this link is
14:42usually quite close. Yes. When I speak
14:46of social determinants, I am referring
14:49to the living and working conditions,
14:52to the economic and cultural conditions
14:55that affect people's health, right?
15:00Because what we see in the population
15:03we support is that poverty, exclusion,
15:07lack of opportunities, living in
15:09conditions of extreme precariousness,
15:12living on the street are aspects that
15:16can sometimes be conducive to substance
15:19use, right? Use can often appear as a
15:24possible response to situations of
15:26economic and social crisis. Yes, in
15:31vulnerable neighborhoods, often marked
15:34by violence and the difficulty of
15:37future prospects, adverse conditions
15:40can also appear that lead people, often
15:44very young, to consume. I say "can,"
15:50because it is not an absolutely linear
15:53cause, of course, but they are indeed
15:56unfavorable and fertile conditions for
15:59problematic use. And of course,
16:02consumption is not limited to certain
16:05social groups, right? But it appears
16:08differently across the various sectors.
16:13In any case, of course, we are all
16:15affected by the characteristics typical
16:18of a consumer society, aren't we? Which
16:22is marked by the immediate satisfaction
16:25of needs, right? The idea that we
16:28achieve happiness through consumer
16:30objects, objects that are never enough
16:32because there is always a new model
16:35that discards the previous one, right?
16:38And it is a consumer society that
16:40divides us, right? Between
16:43never-satisfied consumers and those
16:45excluded from consumption. Both,
16:49ultimately, empty, right? E So, well,
16:57it is a necessary point to establish
16:59because, being an issue so linked to
17:02the social realm, the issue of
17:04consumption, we have to ask ourselves
17:06how to address it, right? And we
17:13believe that necessarily, if we
17:15identify this very close relationship
17:18between problematic consumption and
17:21social determinants, we necessarily
17:24have to take a community approach. The
17:32Jacob Plan, I understand you have
17:34already seen it, right? The plan from
17:382014, which is still not regulated. It
17:44is a law that comes to complement, in
17:46matters of consumption, the Mental
17:48Health Law in a way. You have already
17:52seen it, but I am interested in
17:55highlighting that, on one hand,
17:57consumption is defined there as
18:00problematic insofar as it negatively
18:02affects, right? In a chronic way. The
18:06physical or psychological health of the
18:08subject and their social relationships.
18:11But I am particularly interested in the
18:14fact that within the objectives of the
18:17Jacob Plan, you saw that they include
18:21prevention, assistance, and integration
18:24, right? Regarding prevention, well,
18:28they place it within an intersectoral
18:30approach through direct action by the
18:32State. e They also place, as a second
18:39objective regarding assistance, that
18:41comprehensive free healthcare must be
18:43guaranteed in general hospitals, as I
18:46mentioned at the beginning. But I was
18:51interested, in particular, in the third
18:53objective, which has to do with
18:55integrating and socially supporting
18:57subjects of some problematic
18:58consumption, because it proposes there
19:00as central, a quite interesting way to
19:09approach it, by stating that when
19:11subjects have had problematic
19:13consumption and are in a situation of
19:16vulnerability, psychosocial and social
19:18vulnerability above all, that this
19:25vulnerability threatens the development
19:27of their capabilities, the carrying out
19:29of activities, and puts the success of
19:32the treatment at risk, that
19:33vulnerability. So, the State
19:35incorporates them into special
19:37integration programs. Yes. And those
19:40programs are, uh, fundamentally grants
19:43that have to do with education and work
19:46. Well, making a distinction, you see,
19:49regarding ages, but what I insist I am
19:51interested in underlining is that, uh,
19:54it is how the YACO Plan proposes a
19:56close articulation between treatment
19:59and the integration of the subject into
20:01society. Yes. uh, with integration even
20:06being a condition for the success of
20:08the treatment, it says, uh, in the law.
20:13I think we can even go further and
20:15posit that integration itself, right?,
20:18social participation, is a
20:20non-traditional treatment, not as we
20:23often think of treatment linked to that
20:25individual psychological and
20:28psychiatric treatment, but indeed a
20:30treatment for distress. Uh, and I was
20:33saying, "Integration itself is a
20:35treatment, we could think of it, for
20:37the distress that is at the root of
20:39consumption, right? this idea of
20:44consumption linked to social
20:47determinants and that treatment
20:50requires a community approach where the
20:54person is accompanied to, let's say,
20:57spaces to belong to, to participate in
21:01educational and work spaces. it is not
21:07so common, but rather what we hear most
21:12is the request for hospitalization,
21:15right? The request for hospitalizations
21:18, often prolonged, that, uh,
21:19hospitalizations that, well, as the law
21:21establishes, right? hospitalization is
21:25a valid therapeutic resource at a given
21:28moment, but, well, uh, the idea is that
21:31we can somehow begin to, uh, to
21:36denaturalize in some way the idea that
21:38for a person with severe problematic
21:41consumption, the initial, core, or
21:43effective response is hospitalization.
21:46Yes. Well, uh, regarding the criteria
21:55for hospitalization, what I was
21:57interested in telling you about is the
22:00research we did with, with the team of,
22:03a team of researchers from San Martín,
22:06which we submitted for a grant from the
22:09Lanteri grants of the province of
22:12Buenos Aires, uh, and which we carried
22:15out during 2024 and 2025. we presented
22:20the results at this year's COSAPRO. It
22:25already feels like it was a 1000 years
22:27ago.
22:27Yes, yes,
22:29it's a long one, it has been a long one
22:31.
22:31Yes. Uh, and, um well, what we proposed
22:39there as, as uh yes, as an objective
22:47and as an initial problem, right? Uh, I
22:50mean, what we are trying to do is work
22:52on the factors that intervene in
22:54involuntary hospitalizations for cases
22:56of severe problematic substance use. We
23:00studied the cases at the Mental Health
23:02Emergency Unit of San Martín Hospital,
23:05uh, during uh, 6 months, right? Uh, and
23:12we identified as an initial issue that
23:18even though the law places, as I told
23:21you at the beginning, it places
23:23addictions as part of the mental health
23:26field, right? Therefore, people with
23:30problematic substance use have the same
23:33rights as all those to whom the mental
23:35health law is directed. Uhm. That on
23:41one hand. And on the other hand, the
23:43law states that certain imminent risk
23:45is the criterion for involuntary
23:46hospitalizations, right? If we propose,
23:50uh, if we take those two points,
23:52problematic substance use could be
23:56involuntarily hospitalized just like
23:59mental conditions in general. Yes,
24:03there would be nothing within the law
24:05that contradicts that, contraindicates
24:08that, or prohibits involuntary
24:10hospitalization for problematic
24:12substance use. However, the criticisms
24:16you must have heard more than once from
24:20society, right?,which often appear in
24:23the media, tend to claim that the law
24:27does not allow for the hospitalization
24:30of these cases, right? And these are
24:37criticisms found in the media and are
24:40also taken up by the projects to amend
24:42the law, right? The various projects
24:45that exist. And now again, in a very
24:47short time, a new project to amend the
24:50law is being discussed again. Among
24:54other things, it seeks social consensus
24:57by stating that it must be modified to
24:59be able to carry out hospitalizations
25:02for problematic substance use, right?
25:07So, we asked ourselves, if within the
25:10law there is nothing that prohibits or
25:13does not allow those hospitalizations,
25:17what does this insistence from society
25:20respond to, right? Saying that this
25:25does not happen, that the
25:27hospitalizations do not take place. So
25:30we went to verify what actually happens
25:33in practice, as I told you, in the unit
25:36, it is a 24-hour interdisciplinary
25:39unit, where there is at least a
25:42psychologist and a psychiatrist. uh, 24
25:46hours at the General San Martín
25:49Hospital in La Plata, and we analyzed
25:52all the cases that consulted the unit
25:57between January and July 2024, right?
26:00That presented with problematic
26:01substance use. Uh, we reviewed the
26:05research methodology; it was a
26:08qualitative, exploratory study with a
26:11retrospective design, meaning that we
26:15analyzed cases that had already
26:18consulted the emergency room. What we
26:22did is, they had already consulted the
26:24ER, right? At the time of the research,
26:26they had already consulted. So, what we
26:29did was review the TRI system, which
26:31was the digital medical record computer
26:34system in place at that time. Now, the
26:37implementation of the HCI is more
26:40advanced. Uh, but at that moment that
26:44was the system, and what we did was
26:46extract all the cases where the word"
26:49consumption "appeared. Uh, in those 6
26:52months there were 314 cases; we
26:55reviewed them and filtered those that
26:57actually had to do with a consultation
27:00regarding consumption, because others,
27:03for example, said" denies consumption "
27:05or" person distressed by their child's
27:08consumption situation, "etc. So, from
27:11those initial 314, when we applied that
27:14filter, 281 remained. Yes, that is the
27:18sample with which we worked. Uh, what
27:21we did was create a table for data
27:25collection with different categories:
27:28age, how the person arrived, if they
27:31arrived spontaneously or were brought
27:34by court order, uh, the reason related
27:37to consumption, right? What did it say
27:40regarding the reason for consulting the
27:42ER, for their presence in the ER? The
27:46type of substance consumed, the
27:48frequency of consumption, also uh, the
27:50history of treatment or
27:52hospitalizations, treatment dropouts if
27:55there were any, if they had taken place
27:57, uh, previous consultations for mental
28:00health, to the mental health ER, and to
28:03other specialties in the hospital's ER.
28:08Uh, and in the table we also included
28:10the therapeutic strategy adopted by the
28:13evaluating team and some observations
28:16for each case. What we did, there were
28:20four of us researchers; we divided the
28:23281 cases among the four, and each one
28:26analyzed the situations and completed
28:28the table. Uh, I'll tell you about some
28:33results that can help us see a bit of
28:36what has been happening regarding
28:38accessibility in hospitals for
28:40addressing consumption, especially in
28:43emergency situations. Uh, what we found
28:48is that, well, the average age was 33
28:50years old, that 76%uh, were men, uh,
28:57that 40%had a family contact, and that
29:0160%uh, presented multi-substance
29:04consumption. Uh, and we were finding
29:10some interesting data regarding, for
29:14example, that 55%—more than half—
29:17had consultations in other emergency
29:21specialties and more than half had
29:24previous mental health consultations.
29:29Yes. Uh, the data that had to do with
29:34the main part of our research is, well,
29:39100%of the cases: how many had, let's
29:45say, received an indication for
29:47hospitalization? And it was only 9%of
29:50the cases that received that indication
29:54for hospitalization. But in almost half
29:59of the cases, even without an
30:01indication for hospitalization, the
30:04strategy considered the complexity of
30:06the case because it was evident—I
30:09mean, that consideration of complexity
30:12was evident, because coordination with
30:14other health providers and follow-up
30:17through the emergency room was
30:19indicated, right? That is to say, in
30:23more than 90%of the cases,
30:24hospitalization was ruled out as an
30:26indicated therapeutic strategy. But it
30:29was not dismissed because of that.
30:33That’s what I mean by saying the
30:34complexity of the case is addressed,
30:36because continuity of care is
30:38guaranteed, right? This is quite
30:40different from what usually happens in
30:43emergency rooms when someone feels bad
30:45and goes to a clinical ER, for example,
30:48where they usually address the urgent
30:51situation and don't schedule a
30:53follow-up. Look, when we go to an ER,
30:55they see us, they say," Well, buy this.
30:57"" In any case, come back in 48 hours
30:59if you still have the same symptoms. "
31:01Uh, what has been happening more and
31:03more in mental health ERs, and it's
31:06also a phenomenon of recent years—
31:08it's not that it's inherent to mental
31:10health ERs, but it has to do with the
31:12complexity of the cases—is that it is
31:14very common, very usual, to follow up
31:16on cases in the subacute period. So the
31:20case is seen initially and they are
31:23asked to return the next day, they are
31:25asked to return in 48 hours if there is
31:27no improvement, they are asked to
31:29return in a week, and there are perhaps
31:31cases that have been under follow-up in
31:33the ER for 4, 6 months. Yes. So, I mean
31:39, it is interesting to highlight this
31:41point of the research which shows that,
31:44well, in 90%of the 281 cases
31:46hospitalization was not indicated, but
31:49in almost half, that follow-up was
31:51carried out, right? Uh, which is a
31:56follow-up that involves coordination
31:58with another provider to begin
32:00outpatient treatment while providing
32:02support during the subacute period. And
32:07I was interested in also highlighting
32:09from these data that more than 30%of
32:15the cases presented three points at the
32:17same time, right? Long-term substance
32:21use, previous mental health
32:23consultations, and previous
32:25consultations in other specialties. Yes
32:28. and previous consultations in other
32:30specialties with serious situations,
32:33stab wounds, head trauma, right? Uh, I
32:36mean, uh, 30%of these 281 had been
32:42using for a long time, had consulted
32:45mental health services several times,
32:47and had these types of consultations in
32:50emergency, for example, from this same
32:52ER. Yes. However, even though they had
32:56those characteristics, they are not
32:59cases where hospitalization was
33:00indicated, right? Uh, so I mean, these
33:05are cases that were not reflected,
33:07these are data, sorry, that were not
33:09reflected in the determination of the
33:11therapeutic strategy adopted, right? We
33:16did not find hospitalization orders
33:19that say," Well, the patient is calm at
33:21this moment, but their relative reports
33:24that they were absent from home the
33:26last few days and has three serious
33:28consultations in the clinical ER, so
33:30that is why hospitalization is
33:32indicated. "That type of analysis we
33:36did not find. It is true that the
33:39triage system does not show that data
33:41quickly, that we gathered them during
33:43the research time, which is different
33:45from the care time in an ER, right? So,
33:49uh, well, there is something to that
33:51which we also placed as, uh, as a
33:53research finding to contemplate, right?
33:57the registration systems, uh, because
34:00it's also, well, how to access that
34:03person's history quickly, uh, their
34:06history of care at least. And, uh,
34:10another issue linked to records, I make
34:13this parenthesis, is, uh, that we saw
34:16that it was very, uh, very diverse how
34:19the different teams evolved and
34:22recorded. Yes, because when we, uh,
34:25looked at those 6 months, of course the
34:27Monday team is one, the Tuesday one is
34:28another, the Wednesday one is another,
34:30and, uh, there is a lack of
34:32systematization in data recording, uh,
34:33which is very notable. So, also there,
34:36uh, well, it makes it difficult to, to
34:39see a person's journey because you have
34:41different data. Some weighted one type
34:44of data and others did not. Different
34:47teams record very diverse data with
34:49very different styles. So, that also
34:52makes research questions difficult, but
34:54also diachronic reading. Right? So, uh
35:01what became evident is that, uh, when
35:03evaluating, the synchronic snapshot is
35:06prioritized. Yes. Uh, neither the input
35:09from social support networks nor
35:11previous consultations are taken as
35:13determining factors for hospitalization
35:16. These are not data that are dismissed
35:18in any way. Yes. Uh, but they do not
35:21prove to be determining factors for the
35:22admission criteria. Complexity is
35:25considered, as I was telling you, and
35:28that is why continuity of care is
35:29guaranteed in the strategies, and there
35:32is this somewhat new form of referral
35:34with case follow-up until the referral
35:36is finalized, right? But well, it is
35:42evident, or at least that's what we
35:45gathered in our conclusions, that it is
35:49necessary in cases of severe
35:52problematic substance use to establish
35:55the specificity of the notion of risk
35:59as a process that links the care and
36:02life trajectory of each person, right?
36:08It is necessary to contemplate previous
36:11and current clinical and social aspects
36:14in that evaluation. Yes. Unlike other
36:18presentations like psychotic
36:20decompensations, where there is
36:22something about the synchronic that
36:24allows us to see that a person, due to
36:26certain phenomena, right? If they are,
36:29uh, hearing voices that, uh claim that
36:35others are going to harm them, then
36:36their behavior is driven by that. There
36:39is something about that synchronic
36:41evaluation that, in psychotic
36:43decompensations, for example, allows us
36:45to situate the certain and imminent
36:47risk. In the case of problematic
36:50substance use, the situation is
36:52different. So, there is something about
36:55the specificity that I insisted on—
36:57that’s why I insisted on: well, there
36:59is specificity in the approach, there
37:02is specificity in the hospitalizations,
37:04there is specificity in the risk
37:06assessment. Yes. And there is something
37:09about this research that points to the
37:12fact that we need to think about how to
37:14determine the certain and imminent risk
37:17in cases of problematic substance use,
37:19and that it’s not—it’s not
37:22situated in the law, right? I mean, we
37:24can't ask everything of the law either.
37:26There is something that the law defines
37:29regarding risk, but it is our
37:31obligation, regarding the clinical side
37:33, to define what content or description
37:36that risk has, right? Imminent in
37:39certain cases and, uh, which in others,
37:42right? What clinical value do we give
37:45to that notion, which initially is a
37:48legal, uh, notion, right? Uh, But
37:53anyway, here we have again, right?
37:56Presentations, uh, designated by
37:58consumption within the field of mental
38:00health, with a certain, uh, specificity
38:03, I think, to be considered within this
38:05field, which, I insist, is our
38:07obligation. That, and that is why these
38:11spaces and being able to discuss them,
38:14ask ourselves questions, go to the
38:16clinic, and rethink, and try out some
38:19strategies again to accompany these
38:21complex cases as best as possible. Well
38:26, I'll leave it there and let Lu
38:30continue and...The We will also leave
38:39this part for you later so you have it
38:42in the materials regarding the research
38:45. Um, later, if you want, we can
38:48discuss any questions you have. Well,
38:55uh, thanks, Mer, thanks for the
38:57invitation to everyone as well. Uh, I
39:01am Lucila Romero; following the
39:03introduction, I was Mer's colleague in
39:06the hospital career for several years
39:10and, well, later with the
39:12interdisciplinary coordination and, uh,
39:15working in the ER since my return to
39:18the hospital in 2019 and, currently, as
39:21head of service, following in Mer's
39:24footsteps. Well, it seemed important to
39:29me to pick up on what Mercedes was
39:31commenting on related to
39:36hospitalization. I think it is
39:38important to understand that mental
39:40health hospitalization always involves
39:42the intervention of an
39:43interdisciplinary team that can
39:45evaluate the mental health emergency
39:47situation from an integral perspective,
39:49situated and framed, uh, within the
39:51framework of the mental health law. And
39:54for that, it seemed important to, uh,
39:56contemplate some definitions and frame
39:58the mental health emergency. So, being
40:00able to define it, right? What do we
40:02call a mental health emergency? What do
40:05we call a subjective emergency? And
40:08what role and function does the ER play
40:10, and the, I mean, the general ER and
40:12the mental health ER in particular?
40:15When we talk about mental health
40:17emergencies, we speak of a transitory
40:18situation, right? I mean, uh, we are
40:21not talking about what Mer brought up
40:24regarding the concept of mental health
40:26in terms of what is fluid, let's say,
40:29and that it is a concept that does not
40:32require fixedness, but rather this
40:34possibility of seeing that it is
40:36traversed by, uh, multiple processes.
40:40So, when we talk about an emergency, we
40:42are talking about a transitory
40:44situation that alters a psychic
40:46function and the usual performance of a
40:48person who presents a level of
40:49suffering such that it requires the
40:51intervention of the health team. Yes,
40:54this urgent situation is noticed by the
40:56subject, it can be noticed by their
40:58social circle or by healthcare staff,
41:00but it implies that it must be
41:02addressed, right? Quickly, from that
41:05mental health emergency, the concept of
41:08subjective urgency also emerges, or is
41:11linked to it. We could say. Subjective
41:14urgency assumes the awareness that a
41:17person has of that crisis situation
41:19that interrupts their life. Many times,
41:24addressing a subjective urgency allows
41:26for preventing the establishment of a
41:28mental health emergency, and many times
41:30the mental health emergency determines
41:32a subjective urgency. What is a
41:35subjective urgency? It is the sensation
41:37of extreme suffering that a person has,
41:40regardless of whether others might
41:42evaluate it as such. What does that
41:44mean? That it is a singular sensation,
41:47right? That a person experiences based
41:50on a certain subjective rupture, as we
41:53also call it, or a situation that
41:55interrupts their life and for which all
41:57the resources they had until that
42:00moment are not enough or do not help
42:02them cope. These subjective urgency
42:06situations often trigger mental health
42:08emergencies because they lead to
42:10episodes of impulsivity, self-harming
42:13behaviors, episodes of aggression
42:15toward others, psychotic
42:16decompensations, and, for example,
42:18problematic substance use, among others
42:20. In those situations is where we talk
42:24about the intervention of a mental
42:26health emergency department. Regarding
42:29the Mental Health Emergency Department,
42:30the one I am interested in speaking
42:32about is the Mental Health Emergency
42:33Department at San Martín Hospital. Mer
42:35spoke a little, right?,about the
42:36specific characteristics of the
42:37hospital. The hospital is a
42:39high-complexity general acute care
42:41hospital that offers various approaches
42:43in mental health. One of them is the
42:45emergency department. This particular
42:48department is characterized by being
42:51open 7 days a week, 24 hours a day, and
42:54for a few years now, not always, it has
42:57had an interdisciplinary team.
43:01Previously, even before the law was
43:03passed and during its initial
43:05implementation phase, the emergency
43:07department was a psychiatric one and
43:10was maintained by a psychiatrist. So,
43:13part of this mobile process of
43:15implementing the law and also
43:16understanding the increase and
43:18requirements for intervention from an
43:20interdisciplinary perspective made
43:22those emergency departments become a
43:24team, a true team. They currently have
43:28a psychiatrist, a psychologist, and, as
43:30of very recently, exactly one year ago,
43:32a social worker and a specific nursing
43:35team. I bring this up because it
43:38doesn't happen everywhere and because
43:40it is fundamental and necessary to
43:42achieve the evaluations and support for
43:44these urgent situations. The mental
43:48health law provides that mental health
43:50emergencies must be addressed in
43:52general hospitals, even regardless of
43:54whether a mental health ward exists.
43:58And this is important to bring up
44:00because all hospitals have mental
44:02health teams, so an emergency situation
44:05can often be accommodated by a health
44:07team, even without a mental health ward
44:09, and then addressed by a mental health
44:12team. This is important to convey,
44:16especially regarding problematic
44:18substance use and emergencies caused by
44:20problematic substance use. We currently
44:24know that there are several, uh,
44:26several general hospitals that have, uh
44:29, care teams, some with on-call teams,
44:32and some with what is called a crisis
44:35care unit that acts as an on-call ward.
44:40They do not have 24-hour on-call shifts
44:42, but some do have 12-hour shifts, like
44:44the Rossi Hospital, and 8-hour shifts,
44:46like the, uh, Gonnet Hospital and the
44:48San Roque Hospital.
44:50The San Roque Hospital. Well, this
44:52on-call ward, like the one at Romero—
44:54that is, the ones at San Martín
44:56Hospital and Romero—are the only ones
44:58that operate 24 hours a day, 7 days a
45:00week. What can we say regarding
45:05emergencies linked to problematic
45:07substance use? It is very important to
45:10understand, and within what MER was
45:13saying, that the entry point through an
45:15on-call ward for, let's say,
45:17problematic substance use in emergency
45:19situations, is also the possibility of
45:21understanding them as, uh, a problem
45:24that must be addressed, uh, linked to
45:26health and not to the punitive or
45:28segregative. So, bringing emergencies
45:31linked to substance use into hospitals
45:33already implies a different perspective
45:36from the health team. Yes, to
45:38accommodate some of that suffering as
45:40such, to contextualize it, to listen to
45:43it, and above all, when we talk about
45:45emergencies linked to substance use, to
45:47understand that, in the first instance,
45:49when one speaks of emergencies linked
45:51to consumption, one is often speaking
45:53of situations where there is a risk to
45:55life. And that is important to
45:59understand, because that must be
46:00accommodated in any on-call ward,
46:02regardless of whether there is a mental
46:04health team or not. We have then, what
46:09situations are, uh, acute situations of
46:12problematic substance use? Well, for
46:15example, detoxification or
46:18stabilization. Uh, you have to use that
46:21there, sorry. We're on the slide.
46:24Ah, we're double.
46:26Hope the slide is okay.
46:27Let's see, we're doing fine, right? Yes
46:29, good.
46:31Moving on. Ah,
46:32yes, yes, perfect. It's, it's heard
46:34perfectly. Besides
46:35good. Great. Well, a bit about this. We
46:39have to understand that mental health
46:42emergencies linked to problematic
46:45substance use often arrive with acute
46:47intoxication, overdoses, or, for
46:50example, withdrawal effects, right?
46:54People experiencing acute withdrawal,
46:56and those situations must be addressed
46:59first and necessarily by a clinical
47:01team. If at that moment the urgency is
47:05clinical—and this is important to
47:07keep in mind because when it happens,
47:10one should go to the nearest hospital,
47:12regardless of whether there is a mental
47:15health on-call team—because that
47:17first urgency is addressed, and must be
47:19addressed, by an emergency team,
47:21precisely to prevent that urgency from
47:24becoming an emergency. So, that is
47:28important because it requires clinical
47:30attention and, in a second stage,
47:32attention from the mental health team.
47:37A mental health on-call service often
47:39receives...let's say, what kind of
47:41consultations does a mental health
47:43on-call service receive linked to
47:45problematic substance use? Well, it
47:49receives both spontaneous consultations
47:52, as Mer was saying a moment ago,
47:55people who arrive, let's say, motivated
47:59by the mental health consultation in
48:03terms of their substance use issues, as
48:06well as consultations linked to
48:09evaluations requested by family courts
48:13and also by police personnel, right?
48:17And security forces. These are also
48:19requests that reach the on-call service
48:21and that the health team must be able
48:24to intervene in and evaluate. So,
48:27returning to what I want to be clear
48:29about, which is: what are the urgent
48:32conditions that must be addressed
48:34clinically in the first instance? They
48:38are withdrawal syndromes, in some ways
48:40severe ones, and intoxications, to
48:43prevent them from becoming emergencies.
48:47Once that clinical urgency has been
48:49addressed and evaluated, it is
48:51necessary to establish a risk
48:53assessment, or rather, an assessment of
48:55the situation in the mental health
48:57on-call service. For that, we have
49:00certain evaluation criteria. Earlier,
49:02Mer talked a bit about the context. We,
49:05although we do this with all issues,
49:07right? We try to receive and
49:09accommodate the mental health
49:11consultation situation, to create a
49:13history of that person's health
49:15trajectory and their relationship with
49:17their suffering, in this case, their
49:19relationship with substance use. We try
49:21to gather as much information as
49:22possible, right? Well, what substance
49:24do they use? What is the frequency of
49:26that use? Is there withdrawal from that
49:29use? Are there symptoms linked to that
49:31use? If that consumption is identified
49:34as problematic consumption by that
49:37person or by the network, yes, of the
49:39support figures, whether it be a family
49:42network, uh, or often they are
49:44supported by, uh, social organizations?
49:48That is, uh, a fundamental and
49:49important piece of information to take
49:51into account. What happens? Many times,
49:56in situations of very acute suffering
49:58linked to problematic consumption, we
50:03must count on, as Mercon said, the
50:05assessment and record from those
50:07accompanying the people who present
50:09with problematic consumption, because
50:11often what happens is that the person
50:13does not recognize the problematic
50:15nature of that consumption, and that is
50:17also a piece of data to take into
50:19account in the evaluation. So, let's
50:21talk about the evaluation. When we try
50:25to evaluate, whether by request of the
50:28courts, but also in a situation,
50:30regardless of any request from the
50:32courts, regarding that problematic
50:34consultation, uh, linked to consumption
50:37, we try to assess the level of risk.
50:42The certain and imminent risk. Although
50:47it is a cut, as we mentioned today, a
50:49synchronic cut in the subject's life
50:51regarding problematic consumption, we
50:54must be able to house that history,
50:56that reference to, well, those
50:57consultations that Mer brought up,
50:59right? Of of, well, this person has
51:06shown up a lot of times in situations
51:09of trauma, injuries linked to
51:11consumption situations. That is part of
51:14the evaluation. And if it wasn't part
51:16of it at some point, it is necessary
51:18that it becomes part of it in order to
51:20evaluate the certain or imminent risk
51:22or a potential risk. When we evaluate
51:25the certain and imminent risk, it is
51:30our responsibility, yes, as a health
51:33team and as an interdisciplinary team,
51:36to establish the measure of
51:38hospitalization as an exceptional
51:40measure and obviously, uh, as limited
51:43in time as possible. What do we take
51:46into account, let's say, to think about
51:47those risk coordinates? Well, the
51:50presentation of decompensation of
51:52underlying conditions linked to
51:54consumption; also impulsivity,
51:55hetero-aggression, self-harm attempts,
51:58and, in those problematic consumptions,
52:00uh, that previous relationship in which
52:03one can establish that consumption in a
52:05certain way, at some point, becomes a
52:07risk situation for that person or for
52:10those accompanying them. What are we
52:12talking about? For example, situations
52:14in which one repeatedly sees that the
52:17person has had suicide attempts, has
52:20manifested, uh, self-harm intentions,
52:23has had episodes of escalation within
52:25or outside the family, or has received,
52:28uh, aggression from others linked to
52:31the consumption problem. Well, those
52:34are situations that, yes or yes,
52:35require being taken into account to
52:37establish the risk. How is that risk
52:40determined? Well, it is established
52:42within the legal framework of the law
52:44and with a situated criterion, right,
52:46to be able to establish precisely that
52:48it is an exceptional and transitory
52:50measure. At the San Martín Hospital,
52:54we have an acute inpatient ward, not
52:57just specifically for problematic
53:00substance use, but as a mental health
53:02issue, which is also part of the
53:05situations we admit. That ward is quite
53:10small for the demand that we have been
53:12experiencing, which has been increasing
53:14for several years, not only linked to
53:15problematic substance use, but to
53:17mental health issues in general. It
53:20only has 10 beds. So, what often
53:25happens is that the ward reaches its
53:27capacity and we have to accommodate
53:30cases requiring hospitalization in the
53:32emergency room, which brings another
53:35type of complexity and distress,
53:37because it is not the place where one
53:40could manage an admission. Those people
53:44often remain there waiting for a
53:45referral, either for admission to our
53:47ward or for transfer to another health
53:49facility. Once they enter the mental
53:53health ward, in the mental health ward
53:55they receive, let's say, care from a
53:58much broader interdisciplinary team
54:00than the emergency care team. The team
54:03in the inpatient ward includes
54:05occupational therapy, therapeutic
54:07support, music therapy, social work,
54:09psychology, psychiatry, and nursing
54:11specialized in mental health. 24 hours
54:15a day. Group support mechanisms are
54:20established, as well as individual
54:22treatments within the hospitalization;
54:25that is, individual care and spaces for
54:27group assemblies. Day hospital also
54:31participates in the admissions, in many
54:34, many situations, let's say, as one of
54:36the therapeutic resources used during
54:39hospitalization. But well, that is to
54:42be determined according to the
54:43evaluation made by the different teams.
54:46What is important to clarify is why we
54:48consider hospitalization for
54:49problematic substance use. First, as a
54:51pause to that consumption. We perform
54:53an initial clinical detoxification for
54:56an urgent situation involving
54:58problematic substance use, but we know
55:01that real detoxification from
55:03consumption requires more time. So,
55:06hospitalization appears there as a
55:08possibility for a pause, a pause in the
55:10face of that consumption situation that
55:12at some point became problematic and
55:14generated a subjective crisis for that
55:17individual. During that pause, in the
55:21best-case scenario, what one tries to
55:23do is problematize the consumption in
55:24terms of situating its function, the
55:26consequences, and the costs that this
55:28consumption has for the person and for
55:30those accompanying that person’s
55:31journey, or the fact of having no one
55:33to accompany them. Also to establish,
55:36well, what coordinates or what was
55:38useful to the person at some point
55:40linked to that consumption so that it
55:43wasn't as problematic, and what became
55:45unmoored for that consumption to become
55:47problematic and put them or others at
55:50risk. We try, during that
55:54hospitalization, to work on the
55:56person's involvement in that problem
55:58and the consent for a possible
56:00treatment, and in the best of cases and
56:02in the shortest time possible, to try
56:05to convert that involuntary
56:06hospitalization into a voluntary one.
56:09In some cases, the hospitalization also
56:12helps us to later generate a referral.
56:15For example, we were talking today
56:17about specificity, well, to be able to
56:19generate a referral to a therapeutic
56:20community. Where other conditions must
56:24be met so that the person can continue
56:27their follow-up, whether in a
56:29residential unit or in a therapeutic
56:31community, or some type of organization
56:34that allows for specialized work on
56:36problematic consumption. It is
56:41important, and above all to clarify and
56:45determine that the support and work
56:48with territorial, family, and
56:51relational figures is extremely
56:54important in determining the risk,
56:57right? Imminent risk, and also in the
57:00work during the hospitalization. Why?
57:03Because we know that hospitalization is
57:06limited and that it represents a pause
57:08and a contained effort linked to that
57:10problematic consumption in a risky
57:12situation, but that a whole subsequent
57:15effort is necessary, including, let's
57:17say, both posterior and prior work,
57:19right? But at the moment of
57:22hospitalization, when one thinks about
57:24discharge, one also thinks about the
57:26possibility of building references
57:27outside, and for those references,
57:29continuity of care is extremely
57:31important. Whether from an outpatient
57:34facility, as well as, well, the ties
57:37with social organizations, with
57:39families, with the network in general,
57:42because something that is very linked
57:44to acute situations of consumption, or
57:47rather to the complexity of consumption
57:50in general, but above all to the acute,
57:53is the detachment from what would be
57:55the territory, from the possibility of
57:58building a project, a unique project, a
58:01life project, right? That is why the
58:03role of neighborhood institutions,
58:05schools, workshops, sports, and
58:07community spaces is so important. What
58:11Omer brought up regarding the Jacob
58:13Plan, and this idea of being able to
58:16guarantee inclusion and the possibility
58:18of building life projects for those
58:21people who use substances, who have
58:23been through an inpatient stay, and who
58:26are trying to somehow rebuild their
58:28life project or build some life project
58:31linked to...well, having gone through
58:34mental health issues, uh, sorry, an
58:36inpatient stay. When we think about
58:41problematic substance use, we think
58:44about highly complex issues, regardless
58:47of whether they present a certain and
58:50imminent risk. So, when we don't
58:54evaluate a certain and imminent risk,
58:56but we do evaluate that there is a
58:58latent potential risk that is quite
59:00high, it's not that we consider it
59:02simple or that there is no risk, but
59:04rather, well, this is what we were
59:06bringing up today, right? It relates to
59:10, well, an inpatient stay is not
59:11decided, but a lot of other support
59:13strategies are established that assume
59:16a possibility prior to an inpatient
59:18stay or with the intention of avoiding
59:20that intervention. And in that
59:23intervention, we think about follow-ups
59:25through on-call services, coordination
59:27with social organizations, and linking,
59:29for example, with the community
59:31territory. We work a lot with the
59:34municipality's addiction agency and we
59:37establish a quite close bond and
59:39network there, always trying to think
59:41in and from a perspective of risk and
59:43harm reduction, right? Aiming at
59:47building the person's resources and
59:49their enrollment in the possibility of
59:52building life projects, which we
59:54consider fundamental for a person to be
59:57able to lower their level of
59:59consumption. We do this both to avoid
1:00:03an inpatient stay and post-internment
1:00:06to be able to guarantee the continuity
1:00:08of care, and always from a perspective
1:00:10of risk and harm reduction, right?
1:00:13Understanding that consumption is,
1:00:15let's say, often the solution to other
1:00:17problems for a person, it is a strategy
1:00:19in the face of other ailments. So, to
1:00:22understand that there are different
1:00:23meanings linked to consumption, that
1:00:25there are different trajectories linked
1:00:27to that consumption, regardless of
1:00:29whether it is the same substance being
1:00:31consumed. That we can think that
1:00:34abstinence from that consumption is a
1:00:36strategy, but not the only one, it is
1:00:37not the goal, let's say, it is not the
1:00:39only goal we must aim for. That it is
1:00:42necessary to build strategies for joint
1:00:44interaction with the person who
1:00:45consumes. So, knowing, well, what works
1:00:47for that person, what they need, in
1:00:49what situations they consume, what
1:00:50other strategies they can develop in
1:00:52the face of those ailments that led
1:00:54them to consume. Identify and
1:00:56coordinate with networks, networks of
1:00:58social bonds; when they are family,
1:00:59they will be family, but if not, they
1:01:01will be social networks of another type
1:01:03. And work within the consumption
1:01:05spaces themselves to ensure
1:01:07accessibility. This is fundamental
1:01:11because we have to understand that
1:01:13substance use is a problem that is
1:01:15growing and becoming increasingly
1:01:17complex, and it happens in
1:01:18neighborhoods; we cannot think that the
1:01:20only solution is institutionalization
1:01:22because we would have to
1:01:24institutionalize entire neighborhoods
1:01:26or a huge population. So, we obviously
1:01:29have to think about public policies and
1:01:31approaches within the community. Well,
1:01:35for a closing, some key words, right?
1:01:38Regarding problematic substance use and
1:01:41the emergencies linked to problematic
1:01:43consumption, it is important to
1:01:45identify what the real urgency is,
1:01:48right? And to clear up what the demand
1:01:51is that is often established by
1:01:53judicial bodies, for example, linked to
1:01:56the demand and try to establish the
1:01:58uniqueness of that urgency for that
1:02:00particular person. Remember the scope
1:02:03and limits of an emergency room and an
1:02:05institutionalization. Also, maintain
1:02:08joint work with references and family
1:02:11instances, and above all, always
1:02:13intervene from an integral and harm
1:02:16reduction perspective. Well, I'm back
1:02:23here, I don't know if we're still here.
1:02:26Well, Lucila, well, of course, Lucila
1:02:28and Mercedes, thank you very much. Very
1:02:30clear, very clear. Well, there are many
1:02:34thanks. Well, I'll read some of the
1:02:37comments. Uh, well, someone, let me see
1:02:42, the chat is moving on me, excuse me.
1:02:44Uh, uh, what else? Let's see what I do.
1:02:49Ah, it says San Martín Hospital has
1:02:51high demand, they comment here. That
1:02:53team is the ideal situation. Super
1:02:55clear. Well, thanks. And someone had
1:03:00raised their hand there, Alfonso is on
1:03:02the technical team, if he can enable
1:03:05the microphone so they can speak. Who
1:03:08had raised their hand? I can't see it
1:03:20from here, but surely there is someone
1:03:22who raised their hand a little while
1:03:24ago. Well, Mariela Valenzuela also says
1:03:26," Excellent and very clear. "Thank you
1:03:28very much. Ingrid Charlenque also says
1:03:30it's very clear. Thanks. There it is,
1:03:34ready. Alfonso is notifying in the chat
1:03:36that it is ready. Well, who had raised
1:03:40their hand to speak a little while ago?
1:03:42Carla. I can't see it from here because
1:03:45I have the
1:03:46it says Carla here, I think.
1:03:48Good, Carla. Tell her she doesn't have
1:03:58audio. She has to unmute herself, right
1:04:01? On one hand, Alfonso unmutes, but on
1:04:04the other hand, she also has to press
1:04:07the microphone to be able to unmute
1:04:09herself. Carla Cabañas, there it is.
1:04:14Carla, are you there? Well, Yamila,
1:04:25I'll keep reading while Yamila Baladán
1:04:27Sosa says," Very, very interesting
1:04:29contribution. I am left with a lot to
1:04:32keep thinking about and building upon
1:04:33in the different teams and facilities
1:04:35in the area where I work. In Tigre,
1:04:38María Servín says, "Excellent, thank
1:04:40you very much, Paola." The same here.
1:04:43Excellent class, very clear
1:04:44contributions. Uh, well, oh, they say
1:04:48she lowered her hand. Well, well, Carla
1:04:51, if you if you wanted to speak, uh, of
1:04:53course, just let us know, write to us
1:04:55again and raise your hand once more. Uh
1:04:59, Romina Pet says, "The work of the
1:05:01personnel working in mental health is
1:05:03admirable." Yes. Well, many thanks,
1:05:06many comments along those lines.
1:05:10Maybe one comment,
1:05:12yes,
1:05:13I mean, because several, beyond what we
1:05:16have been reading here, right? It is
1:05:21true that there is an intention for all
1:05:22this to work in a certain way, and
1:05:24especially for the health teams. It is
1:05:28also true, as we were saying, that the
1:05:30increase in consultations and demands,
1:05:32not only in problematic consumption—
1:05:35because we must also understand that it
1:05:37is one of the problems in mental health
1:05:40, but not the only one—and the
1:05:42difficulty in accessing appointments,
1:05:44also for outpatient treatment,
1:05:46sometimes has too much delay, too much
1:05:48waiting; that many times health teams
1:05:51must, I mean, that it is the obligation
1:05:54and the...(there seems to be an open
1:05:56microphone, I think), um, that many
1:05:59times, uh, and we insist a lot on
1:06:01building the ability for teams to
1:06:03establish a bond of conversation and, I
1:06:06would say, to inform; it is our
1:06:08responsibility to inform those who come
1:06:10to the ER about, well, the conditions
1:06:13in which we work, the particularities
1:06:15and the resources we have, and that
1:06:18many times we do what we can, which is
1:06:20not ideal, right? But we always try to
1:06:23make it the best possible. We know it
1:06:26is not ideal and that many people go to
1:06:28the ERs and wait for many hours, but it
1:06:31is also true that sometimes there are
1:06:33few teams and that in general ERs we
1:06:36sometimes share spaces with other
1:06:38disciplines. So, sometimes it is really
1:06:41overwhelmed, not only by mental health,
1:06:43we understand that, and we are also
1:06:45aware that it happens and that it is
1:06:47one more factor that complicates and
1:06:50sometimes sharpens the consultations,
1:06:52right? Because people obviously get
1:06:54restless, and that also generates a lot
1:06:56of distress. We know there is no answer
1:06:59, not just regarding mental health, but
1:07:01in general for the many rights
1:07:03violations we face as a society in our
1:07:06current context, and all of that
1:07:08obviously impacts our mental health.
1:07:10That is why there is also an increase
1:07:12in demand. Well, I see you responded to
1:07:18that comment, so I will continue. Paola
1:07:20says, "Good morning, very interesting.
1:07:22I wanted to know if in the Altos de San
1:07:24Lorenzo neighborhood there is any
1:07:26community organization that works on
1:07:27substance abuse issues." Eh, Claudia
1:07:30Ferreira says: "Such great
1:07:32contributions and work, but the
1:07:34day-to-day is very difficult. Eh, well,
1:07:36for various reasons: high demand, few
1:07:38resources, and mental health services,
1:07:41even though, I insist, from my space...
1:07:43well, emergencies. Evidently, she works
1:07:45in emergencies." Eh, well, eh, Aníbal
1:07:47Sosa Juárez, excellent, thank you very
1:07:50much. Eh, what else? Well, nothing, eh,
1:07:54Carla Cadaña, it's the same, right? Eh
1:07:56, it's clear she couldn't turn on her
1:07:58mic. There it is. Eh, excuse me,
1:08:01exactly what I wanted to raise is, eh,
1:08:03eh, well, very demanding and complex at
1:08:05the time of accompanying patients to
1:08:06the emergency room. Eh, Carí Anaí
1:08:10says, "There are many of us
1:08:11professionals who can work on this
1:08:13issue, but they won't authorize job
1:08:14positions for us," she says. Well, and
1:08:17María Paz Actis says, "Very difficult
1:08:20to assess the imminent risk, right? In
1:08:23substance abuse cases, since people who
1:08:26use substances are often permanently
1:08:28exposed to risk. Eh, Mónica Sauso says
1:08:33, Suazo, sorry, she says," To what
1:08:35extent can the criminal justice
1:08:37response to adolescents with
1:08:38problematic substance use help solve
1:08:41the problem, and what role should
1:08:43prevention, social inclusion, and
1:08:45treatment policies play? "Well,
1:08:52everyone, eh, not, eh, regarding the
1:08:55previous point about the certain
1:08:58imminent risk and the acute, let's say,
1:09:01and complex nature of what we were
1:09:04discussing today, what is important is
1:09:07to establish the significance of social
1:09:10organizations in the territory, of
1:09:13clubs. This seems important to us,
1:09:15doesn't it? Let's say, it is not minor
1:09:19that they are trying to promote a club
1:09:21law in the Senate; let's say, in terms
1:09:24of being able to think about the
1:09:26importance of those spaces for support,
1:09:29for enabling the possibility for people
1:09:32to meet, to have, eh, to build
1:09:34interests, projects, goals linked to
1:09:36their own age, right? Because the truth
1:09:40is, young people at that age should be
1:09:43trying to build some sort of interest.
1:09:46And with others their own age. And
1:09:48often there are factors that dictate
1:09:50they be elsewhere, looking after their
1:09:52families or alone on the streets. And
1:09:55it’s not that the idea is to judge
1:09:57the families, right? Because those
1:09:59families are also affected by a lot of
1:10:02factors—yes, of vulnerability,
1:10:05especially, and of violence. Substance
1:10:09use has been a response in these
1:10:10neighborhoods for many families too,
1:10:12and that, well, implies health policies
1:10:14and, let's say, intervention at a
1:10:16national level in the neighborhoods, of
1:10:18care, and of understanding what is
1:10:20actually happening there, right? Not
1:10:23just substance use, but also
1:10:24consumption linked to gambling. This is
1:10:27real and it’s happening, and the
1:10:30economic need and the need for food
1:10:32make people have to fall into these
1:10:34patterns of consumption many times.
1:10:38It’s not just, let's say, we aren't
1:10:39talking today—Mer said it—but we do
1:10:41have to establish the relationship with
1:10:43social conditions. Perhaps there are
1:10:47different types of consumption, but
1:10:48social conditions do determine one type
1:10:50of consumption or another and also the
1:10:52relationship to that consumption. So,
1:10:55social policies are fundamental. When
1:10:59we think about...it’s not that we are
1:11:02saying the specialized professional
1:11:05health field has nothing to contribute,
1:11:07but it’s not without recognizing and
1:11:10fostering the work done in the local
1:11:12area, let’s say. Because perhaps,
1:11:17obviously, what we try to aim for is a
1:11:19connection with that local area, to be
1:11:21able to think about how the health
1:11:23system can create accessibility for
1:11:25those people who are in constant
1:11:27contact with the person using, with the
1:11:30young people using, and can support
1:11:32certain trajectories and identify:"
1:11:34Well, this situation is now ready for a
1:11:36hospital consultation. "Because what
1:11:39ends up happening is that often they
1:11:41arrive already in situations that are,
1:11:43let's say, more urgent, and there it is
1:11:46super complex to provide answers for
1:11:48everyone. From the ministry as well,
1:11:51and a bit taking from what Mer was
1:11:53saying, which we didn't mention, but
1:11:55the Undersecretariat of Mental Health
1:11:57is also trying to accommodate through
1:11:59evaluation, let's say, and because,
1:12:01well, this thing where many of these
1:12:03situations are judicialized, right?
1:12:06Because it’s true, since access to
1:12:08appointments is so difficult, what many
1:12:11families do is go to the courts and
1:12:13file for an evaluation request. Not all
1:12:16of those requests for evaluation meet
1:12:19the criteria for imminent risk when
1:12:21assessed, which doesn't mean they
1:12:23aren't complex—we’re back to that
1:12:25again—but they haven't had any prior
1:12:27evaluation or contact with the health
1:12:29system. So, from the undersecretariat,
1:12:33we are trying to accommodate this by
1:12:34scheduling appointments so they can be
1:12:36evaluated in another setting, to see if
1:12:38it’s possible to provide follow-up or
1:12:40inclusion in a residential unit. They
1:12:43have even accompanied very extreme
1:12:45situations until home evaluations,
1:12:49right, home evaluations, until, for
1:12:50example, they decide, well, yes, it’s
1:12:52a situation that can no longer be
1:12:53managed at home, and then they
1:12:54coordinate with a hospital. Many times
1:12:57we have provided accommodation for a
1:12:59couple of days to establish that pause.
1:13:01We try to invent, yes, as much as
1:13:03possible to be able to accommodate
1:13:06those suffering. It is not enough. That
1:13:09is real, it is not enough. But well,
1:13:11the idea is to build from
1:13:14it is not enough because we are also in
1:13:16a national context that is catastrophic
1:13:20that is catastrophic in terms of every
1:13:25order that we could possibly identify,
1:13:28right? And that is precisely why we
1:13:32wanted to highlight the link between
1:13:35mental suffering and social
1:13:38determinants, because no matter how
1:13:41many teams we put in the emergency
1:13:44rooms or how many beds we open in each
1:13:47hospital, there is a point where we,
1:13:50from the provincial health providers in
1:13:53this case, are trying to do the best we
1:13:57can. And we do a lot, right? In a
1:14:02context where suffering keeps growing
1:14:06in quantity and complexity because
1:14:09living conditions are absolutely, are
1:14:13absolutely precarious. People are
1:14:18having their rights violated in ways
1:14:21that we haven't seen in recent years,
1:14:24right? That we haven't seen before, I
1:14:27would say. Plus the cuts to the
1:14:30programs, the Remediar program, let
1:14:33alone the programs that were all
1:14:36measures of care, right? And let's say,
1:14:41modalities of care for vulnerable
1:14:43population groups. When we don't have
1:14:47those programs or when those programs
1:14:49are underfunded, plus the living
1:14:51conditions that are becoming evident.
1:14:56Well, in the midst of this, we have
1:14:58hospital beds that have grown in number
1:15:01by almost 70%. The teams, speaking of
1:15:07the teams there, the teams of
1:15:10professionals, like never before in
1:15:14these last few years, residents trained
1:15:18in public hospitals have joined the
1:15:22hospital staffs. Yes. uh, in a way that
1:15:27, no, I mean, I mean, when I finished
1:15:29my residency in 2015, nobody was hired
1:15:32directly, nobody. So, uh, well, I had a
1:15:35fellowship, I was able to, there were
1:15:3810 fellowships for the whole hospital.
1:15:40In the hospital there are 3,500, 1,500
1:15:43eh workers, and only 10 for everyone.
1:15:47Well, in recent years what the province
1:15:50has done is hire residents in a way
1:15:53that is much more, well, planned,
1:15:58looking at which specialties are
1:16:00strategic, right? So, many, many
1:16:04professionals have been hired in that,
1:16:06in that context, right? So, we've grown
1:16:09in infrastructure resources and human
1:16:11resources, but in a context of
1:16:14financing and living conditions that
1:16:16are getting worse, with the effects we
1:16:19emphasize on mental suffering. In this
1:16:23context, we are also dealing with these
1:16:25training instances with, I mentioned
1:16:28the fellowships before, I mean, we had
1:16:30a year of research also subsidized by
1:16:33the provincial government to situate
1:16:35some issues regarding modifying our
1:16:37practice, which isn't research for
1:16:40research's sake, but what we say is,
1:16:42well, in these cases we have to be able
1:16:45to think about certain imminent risk in
1:16:47another way, right? ultimately, it is
1:16:51to guarantee better care. So, well,
1:16:55it's in this whole context that we are,
1:16:58after, uh, while we are in this
1:17:01national context, there is some, from
1:17:04time to time, a certain overflow of
1:17:06hospitals that, well, we try to do the
1:17:09best we can, but I insist that quite a
1:17:12lot is being done. Regarding the Altos
1:17:16de San Lorenzo matter,
1:17:21uh, there are the SAPS, and in the
1:17:23hospitals there are the services of,
1:17:26what is it called? uh, the services of,
1:17:31uh, programmatic area and health
1:17:34networks, which is also, uh, from
1:17:36recent years, starting in 2020, 2021,
1:17:39when territorial articulation health
1:17:42services were incorporated into the
1:17:45hospitals. Yes, in Altos de San Lorenzo
1:17:48there is the SAP working, a territorial
1:17:50service that carries out health posts
1:17:52and also handles the mental health and
1:17:54substance abuse part. Both the San
1:17:56Martín Hospital and the Reencuentro
1:17:58Hospital work in the Altos de San
1:18:00Lorenzo area. So, in any case, some
1:18:04coordination can be done if they
1:18:06require intervention, and surely these
1:18:08services are familiar with the specific
1:18:10organizations that are in that
1:18:12neighborhood. So also, if you'd like,
1:18:16you can leave us an email or some
1:18:18contact information so we can pass it
1:18:21on to the SAPS teams at the two
1:18:23hospitals, so they can address that
1:18:25issue or facilitate that coordination
1:18:27with the organizations in Altos de San
1:18:30Lorenzo.
1:18:32And regarding the other question, which
1:18:34perhaps had to do with this lowering
1:18:38the age of criminal responsibility,
1:18:40right? as a possible solution to
1:18:43substance use. Truthfully, I don't
1:18:47believe it is. Not even for adults,
1:18:51let's say, has detention been a way to
1:18:54work with people so they can be
1:18:57included in society in a different way,
1:19:00let's say. With children, they really
1:19:03are just children. What we have to ask
1:19:05ourselves is what living conditions
1:19:07we've been able to guarantee them and
1:19:09what our shared responsibility is for a
1:19:1214-year-old child to be carrying
1:19:13weapons, uh,
1:19:16let's say, carrying weapons or entering
1:19:19places and exposing their own life to
1:19:21consumption, let's say, to being able
1:19:24to put others at risk or putting
1:19:26themselves at risk without any kind of
1:19:28awareness. Even today is Suicide
1:19:32Prevention Day, so we also have to
1:19:34incorporate that topic into a current
1:19:37issue that is growing, especially in
1:19:40young people and older adults. So, it
1:19:44has a lot to do with social
1:19:46determinants. I mean, what we have to
1:19:49think about is that mental health
1:19:51problems are, I mean, social
1:19:52determinants are fundamental to being
1:19:54able to analyze them. So, in no way, at
1:19:57least I speak for myself, but I think
1:19:59we also believe that this law comes to
1:20:02solve anything, but rather it comes to
1:20:04lock away and make us not see or
1:20:06believe that there isn't a problem that
1:20:09is the responsibility of the national
1:20:12government, uh, to be able to respond
1:20:14and take charge with health policies
1:20:17and, let's say, not just health
1:20:19policies, but public intervention
1:20:21policies in general, right? to be able
1:20:24to provide what we were saying in the
1:20:26plan, to be able to think about
1:20:27scholarships, accessibility, education,
1:20:29guaranteeing rights, that is basic to
1:20:31be able to think that a person can
1:20:32develop, and especially a young person
1:20:34in a way
1:20:36Yes. the focus, the focus, like what I
1:20:38was saying regarding how the focus
1:20:41shifts from the social order of rights,
1:20:43well, it's the same structure in
1:20:46different areas, right? When the focus
1:20:49is placed on the social order, on the
1:20:52punitive, on confinement, on isolating
1:20:55or separating what, uh, makes up a
1:20:58supposed social order, right? So, there
1:21:04are laws of this kind where, well, the
1:21:07focus is going to be on locking up more
1:21:10and more kids or everything that has to
1:21:14do with that, with all those strategies
1:21:17, if you will, or interventions linked
1:21:20to punishment. In no way is there a
1:21:25concrete rehabilitation effort in that,
1:21:28at least it's not the core focus, even
1:21:31though there are some very interesting
1:21:34organizations that are working in
1:21:36confinement conditions, in prisons. Uh
1:21:43but well, it is, I am interested in
1:21:45conveying that there are issues that
1:21:47are like part of the same logic, right?
1:21:50So, it is in the logic that addresses
1:21:53the subject of rights and, therefore,
1:21:55we situate ourselves in what is
1:21:57production, prevention, and treatments,
1:22:00especially in outpatient terms, even if
1:22:03they are narrow, non-traditional. Do we
1:22:07position ourselves on that axis or are
1:22:10we on an axis more linked to, uh, well,
1:22:13that, to the individual and to what
1:22:15guarantees a certain social order taken
1:22:18in very, very particular terms, right?
1:22:21Yes, which also goes hand in hand with
1:22:24the proposal to reform the law. We are,
1:22:29we are well past our time already,
1:22:31right?
1:22:34We are quite over time. Uh, I'll read
1:22:37the last comment from Yamila Sosa, she
1:22:39says," I also appreciate that you have
1:22:40committed to this issue of
1:22:42institutionalization. being a very
1:22:45sensitive topic, as you anticipated at
1:22:46the beginning, not only because of the
1:22:48media discourse, but also because of
1:22:49the experience of many specific
1:22:50families. It is a good contribution to
1:22:53share with the community, it helps us
1:22:55better understand the state of things.
1:22:58Well, Claudia had raised her hand, if
1:23:00it's possible, Alfon, uh, enable her
1:23:03microphone and keep it brief, a brief
1:23:05response as well because we are quite
1:23:07tight on time, so we can, well, bring
1:23:10this to a close. And I want to clarify
1:23:14again while Claudia's microphone is
1:23:16being enabled that, well, you have the
1:23:18part of the block that corresponds to
1:23:20Rosy uploaded to the PEP and Fabricio
1:23:23Castellanos who is part of this block
1:23:25two, you will also find him there. The
1:23:28class is recorded and uploaded to the
1:23:31PEP. Uh, well, can you enable Claudia,
1:23:34Alfon, so we can close there.
1:23:37Hello, yes, good morning. I am already
1:23:39enabled, actually. In these last
1:23:42comments you answered my question a bit
1:23:45. Mercedes and Lucila, thank you very
1:23:48much. Everything was very clear, and
1:23:50I'll keep working on this. Uh, the
1:23:53day-to-day is quite tough. I think most
1:23:56of my colleagues have explained that we
1:23:58are all overwhelmed, collapsed by the
1:24:00on-call shifts. From my role as head of
1:24:05emergency, I try to change this
1:24:07paradigm, to work with all citizens as
1:24:09subjects of rights, and well, we are on
1:24:12that path, but the task is very
1:24:14difficult. Just to give you an example,
1:24:18I am on my cell phone in the office,
1:24:20and we work in mental health urgencies
1:24:22within the emergency network of the
1:24:24local hospitals. So, well, we continue
1:24:29on that path. Thank you very much.
1:24:33Claudia, thank you.
1:24:36Well, let's bring this meeting to a
1:24:39close then. I just copied the email
1:24:41that Paola shared, Lorenzo, so And well
1:24:45, thank you both very much for this
1:24:48class. Thanks, and well, we will see
1:24:51each other next time. Thank you very
1:24:53much.
1:24:53Thanks. Take care.
1:24:55Thanks. take a photo, but it wasn't the
1:24:58right time Amen.

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