This paper is the result of the training experience provided by the Center for Adolescent Health Studies (NESA) of the State University of Rio de Janeiro (UERJ) from March to June of this year. The experience was made possible by the Residency System of the Provincial Training Directorate of the Ministry of Health of the province of Buenos Aires, Argentina, of which I am a member. It is an intensive postgraduate professional training system in public health.

Its current regulations state that during the third year, residents have the opportunity to undertake a “training program”, that is, training in a sector or area that is not offered by the institution to which they belong, whether outside or within the country. The objective of this training is to contribute to the education of the resident both by enriching their field and by exchanging knowledge with other professionals and other institutional realities.

As a psychology resident at the M. Larrain Hospital in Berisso, province of Buenos Aires (Argentina), I decided to undertake this training through the Mental Health Sector of NESA. The reasons that guided my choice were: a) the specificity of adolescent health care; b) the development of the three levels of care; c) the approach through an interdisciplinary team; d) the psychoanalytic orientation of the sector.

The practice of psychoanalysis in a health institution that encompasses the three levels of care and an interdisciplinary approach would be considered impossible by many psychoanalysts, and by a part of the collective imagination. Therefore, it is pertinent to clarify that it was not the care that motivated this choice. First, because it already constitutes an important part of my practice at the M. Larrain Hospital; second, for ethical reasons: the word is the psychologist’s main tool in the face of human suffering and, in this case, the difference in language could cause an unnecessary obstacle. In addition to knowing the effects that a transference bond can cause, and given my conditions of stay in this country, I could not guarantee its viability or adequate work.

Having made this clarification, I will list the initial objectives of this training and then present the structure of the work:

• know and differentiate how adolescent health care is organized at the primary, secondary and tertiary levels of care;
• participate in the activities that the Mental Health Sector develops at each level, its objectives, theoretical arguments and results;
• discover new strategies for adolescent health care and exchange with professionals from different areas, especially mental health;
• have an approximation of the reality of public health in Brazil, in general, and in NESA, in particular;
• transmit this experience, once completed, to my Argentine colleagues, with the aim of optimizing institutional resources and establishing actions that are a specific response to adolescent health care.

The paper is structured as follows: I will first briefly consider the legal framework of current public policies that define the practice of professionals responsible for adolescent health in Brazil, and therefore at NESA. I will then develop the common points and differences in the three levels of care, describing the activities and projects in which I participated directly or indirectly, outlining their objectives, methodology and results. Finally, I will draw some conclusions about the experience.

MY TIME AT NESA

Health in Brazil has been organized since 1988 as a Unified Health System (SUS) and is considered a right of all, and it is the duty of the State to guarantee it based on the constitutional reform that took place that year.

Following this line, but specifically linked to adolescent health, the Statute of Children and Adolescents (ECA, Law No. 8,069) was created, which maintains the “Doctrine of Comprehensive Protection”. From that moment on, professionals are required to report to the Guardianship Council (an organization made up of community members who must ensure compliance with the ECA in the municipalities) any situation in which the health of adolescents is threatened. In practice, situations of violence, of any kind, are the most common. It is in this political and legal context that health actions for adolescents in Brazil and, therefore, at NESA are carried out.

The institution has been operating since 1974, initially being only a clinical unit. It was its growth and institutional recognition that led it to become, in 1995 and to this day, a teaching-care center of reference in the three levels of care.

In addition to care, NESA’s main areas of emphasis are teaching, research and training. It is true that its university origins require this structure, but in practice it could not exist. One perceives an environment of motivation for knowledge and exchange with other disciplines that is sometimes not easy, but not impossible. I consider it almost a concern of the teaching team to convey the need for this exchange for comprehensive care for adolescent health, making it an essential factor for the training of participating professionals (residents, undergraduate and graduate students) in the public health field.

They are constant in the activities at the three levels: supervision spaces, interdisciplinary meetings and research.

The Mental Health Sector is made up of five psychologists and one psychiatrist. Psychoanalysis is the main theoretical axis at all three levels, which recently led the sector to call itself the “Mental Health and Psychoanalysis Sector”. This expresses the conviction that what characterizes psychoanalysis is a particular listening beyond the context, derived from an ethical position regarding human suffering that gives it its specificity and constitutes its contribution. The demands to which it responds are varied, whether for the emergence of the subject or for the self-management of an institution, making them active agents in the face of their discomforts.

In the same vein, the analyst’s know-how allows us to convey that work in an interdisciplinary team does not consist of reducing differences, but in learning to work with them, thus maintaining the specificities. The opposite would be to believe that it is possible to eliminate structural misunderstanding.

In the ward, the importance of teamwork is conveyed, in addition to the daily routine, in an interdisciplinary meeting whose objective is to discuss and evaluate issues related to hospitalized patients and situations that arise from the dynamics and institutional coexistence. This idea is also developed in the organization of events by the party committee, which allows for a different encounter between the team and the patients, which has results in practice.

Mental health care and its specificity in the ward are supervised by the referring psychologist. The work is based on the articulation between psychoanalysis and the hospital, considering the latter a medical field par excellence, where the offer of listening seeks the emergence of a subject in a situation that, generally, turns him into an object. The particularity of the adolescent constructs the cases, just as hospitalization is a cut in the life of a subject, since the disease implies a reality that erupts in the daily life from which the adolescent is separated during this time. The emphasis on work is also highlighted, in addition to the dialogue with other discourses, accompanied by the reading of texts.

Depending on the case, family members require care or some intervention, but they also have access to the so-called Family Group, which is coordinated by social services and nursing, and mental health is invited to participate. The aim is for family members to be able to express their doubts, complaints and questions in a space where the regulations that permeate coexistence in the ward can emerge. This group tries to contribute to the improvement of the adolescent, as do the visits of the Doctors of Joy. There is also a space with a specialized recreation therapist and an incentive to read with the UERJ Reading Program (LerUERJ).

In secondary care, adolescents receive personalized outpatient care. An active coordination of the different specialized clinics is attempted, many of which are part of ongoing programs and projects.

The cases treated by the mental health team are varied and referred mainly by different professionals from NESA itself, making spontaneous demand very difficult. Currently, the massive demand received is an issue for the sector, which involves the team’s work of welcoming and assessing, for subsequent referral of each case, according to the particularities of the adolescent.

This team also includes psychology residents, trainees and interns, who are monitored and supervised in their work. In addition, the psychology residency, because it is linked to the university, also has a space for supervision and training in psychoanalytic clinics (the only clinical-institutional residency in Rio de Janeiro), with its preceptor.

In primary care, the development of comprehensive and interdisciplinary training and qualification of health professionals in different areas stands out. To this end, NESA is dedicated to producing technical and pedagogical material, the methodology of which was developed in conjunction with the Center for Educational Technology in Health (NUTES) of the Federal University of Rio de Janeiro (UFRJ). The development of critical thinking results in modules in which knowledge is presented as incomplete and can only be produced in conjunction with the needs of the professionals, services and clientele to which they are linked. An example of this are the modules recently developed by the Project Network for Teaching Support, Assistance and Care for Adolescent and Young Women (RAMA), whose general objective is to contribute to the training of health professionals, from an intersectoral perspective, for the prevention and confrontation of violence against adolescent and young women.

I had the opportunity to participate in both the final corrections and the pilot test of these modules, which the interdisciplinary team developed for the next national training session with the purpose of raising awareness among professionals about detecting these cases in care. In both experiences, the professionalism with which they were carried out was conveyed. The open exchange of opinions between the different professionals and the team gave rise to an exercise in joint thinking about a non-closed product.

Also, participation in the Free Space for Guidance on Sexuality and Health (ELOSS) program and the Program for Guidance on Sexuality, Prevention of STDs and Distribution of Condoms (PROSS) allowed me to compare, in practice, policies in reproductive health.

In Argentina, Law No. 25,673 on Sexual Health and Responsible Procreation guarantees the distribution of condoms, but in practice there are barriers to accessing them. For example, medical examinations are not performed on minors under 18 without the presence of a responsible adult. This closes an important gateway for adolescents to talk about issues related to their sexuality. Nor is there a strategy to provide consultations in another way.

PROSS is an open space where adolescents can go alone to obtain guidance and information on these topics. Interestingly, the distribution is carried out mainly by interns trained by the project’s interdisciplinary team. In an attempt to reduce the distances that make consultation difficult, they offer a place for transmission and reference for young people and training for future professionals.

The ELOSS project was created to serve adolescents and health and education professionals who are interested in clarifying doubts, deepening their knowledge or work on sexuality and reproductive health. To this end, there is a space with a variety of educational materials available for consultation or loan.

The interesting thing is that the professional training that these projects provide is based not on the transmission of information, but on ethics: it is not enough to simply provide information or distribute condoms; it is important to provide responsible information that offers young people a reference point, along with guidance. In this context, I was able to learn about the work of the team in the field by participating in a transmission experience at a school.

Another setting for participation, motivated by the desire to hear more health professionals in action, were the “Interinstitutional Forums for Mental Health Care for Children and Adolescents in the State of Rio de Janeiro” and lectures by the Center for Studies and Health Promotion of Rio de Janeiro, among others. These are places for the active exchange of opinions and possible solutions to problems such as the lowering of the age of criminal responsibility from 18 to 16; the relevance of the ECA in practice; and the effect of the Maria da Penha Law (nº 11.340), since, in fact, the determinant of the measures and the situation of vulnerability in which these women find themselves raise the question of whether this law does not silence them further.

RESULTS AND CONCLUSIONS

Participating in the sector’s activities at the three levels of care allowed me to get to know NESA in practice through daily exchanges with institutional dynamics and professionals. This knowledge will never be complete, but it has the added value, for my training, of being the product of the inevitable comparison with the reality of healthcare in Argentina.

On the other hand, it would be ignorant and even naive to deny the difficulties that the public system imposes on NESA and that the relationships between knowledge and power impose on the dynamics of any institution. However, the objective of providing comprehensive and high-quality care to adolescents prevails in everyday life, as well as professional training in this field, which implies interdisciplinary training.

The Psychoanalysis and Mental Health Sector participates by maintaining a comprehensive view of adolescents, which also recovers their singularities, an example of a conception of psychoanalysis “in extension”, that is, developed in other scenarios and in active dialogue with other disciplines.

To conclude, I can say that NESA is currently an exception in the reality of health in Brazil. Its results have recently led it to be considered the first Latin American reference in adolescent health and one of the four world references on the subject. Congratulations to the entire team and my thanks, especially to the mental health team, for allowing me to participate and learn about the work they do. I hope that the transmission of this training bears fruit and that experiences like these proliferate in favor of the quality of professionals in training in the public health system.