The impossible mission of psychological therapy in public health: “With appointments every month and a half you do not establish a bond with the patient”

More and more young people come to the office of Belén Hernández, a 59-year-old clinical psychologist who practices in a private center in Madrid. “They are frightened by the predictions of a black future that a generation before theirs makes, who knows nothing of her world or the one they will have to live in,” she recounts. One of these young people who came to her office did so with the help of a friend who snuck in the session she had scheduled. He could not pay it, she was on the verge of suicide and in the Madrid public health system she had an appointment with a psychologist in a year’s time, as Hernández recounted this weekend in a letter to the director in this newspaper.

“This week a 23-year-old man without financial resources has gone to an emergency department in a public hospital in the Community of Madrid, absolutely desperate and with a very high risk of suicide. He comes out with a prescription for an anxiolytic, an antidepressant that will take about three weeks to start taking effect and with a referral to the Psychology Department. 48 hours later, he receives a call to inform him of the date of his first appointment in Psychology: January 15, 2024. A whole message from public health to its users: if you do not have enough money to pay a private psychologist, the Suicide becomes an acceptable alternative. Is anyone thinking of doing something?” he wondered.

The letter, written as a call for help to show the “harsh reality” that many people go through, has touched many fibers in a society that is increasingly aware of the problem of mental health. The lack of clinical psychologists in the system makes getting an appointment with one out of reach for many patients who would need one. Once treated, sessions are as short as half an hour and are often spaced a month and a half apart. “Thus it is impossible to establish a bond of intimacy. If you date a person and he tells you something very important about his life and you don’t see him again for 45 days, you can’t establish that link. In the end, people don’t get hooked, they feel that the problem is not being solved and they don’t go to an appointment”, explains Hernández.

Spain is very far from European standards in mental health care. There are six clinical psychologists per 100,000 inhabitants in the public network, three times less than the European average. Every year there are more than 200 positions for resident internal psychologists (PIR), and to reach these standards it would take more than double. Psychiatrists are also in short supply: 11 per 100,000 people, almost five times less than in Switzerland (52) and half that of France (23), Germany (27) or the Netherlands (24).

Primary care physicians, already overwhelmed, do not have the resources or the time to treat problems of a psychological nature. Given the impossibility of referring them to therapy, they often end up prescribing anxiolytics, as Vicente Baos, a specialist in Family Medicine, told a podcast in EL PAÍS.

The pill thus becomes the only solution received by many patients who would need therapy, but do not obtain it in public health and cannot afford it in private, where each one-hour session is around 50 euros. And that is reflected in figures. The consumption of tranquilizers does not stop growing: one in 10 Spaniards between the ages of 15 and 64 take them, according to the latest survey on alcohol and other drugs (Edades), published this month by the Ministry of Health.

These growing mental health problems are also reflected in the number of suicides, which is the leading external (non-natural) cause of death in Spain: in 2021, 4,003 people took their lives, according to INE data. And the trend worsened in the first half of 2022 (latest figures available): 2,015, which if repeated in the following six months would give a figure of 4,030 in the year.

A study by the Anar Foundation alerted last December to the fact that only 44% of minors between the ages of 13 and 17 who have contacted them in the last three years due to suicidal ideation or suicide attempt have received psychological care, either within the public health system or privately.

As various studies have pointed out, the pandemic has aggravated the situation. Hernández notices in his clinic that the sequelae continue and he believes that they will still last. “It has been very complicated because it is an age in which social contact with your peers and less with the family is very important; being locked up has taken its toll ”, he assures.

Public administrations have begun to move in the face of this reality, but it does not seem that they are doing so fast enough. The Department of Health of the Community of Madrid, where the case reported by Hernández in his letter occurred, explains that it does not know what could have gone wrong, because it does not know the specific case, but it assures that when suicidal behavior is detected, a psychiatric appointment is made in less than seven days.

“There are psychiatrists on duty in the emergency rooms of all hospitals with a 24-hour Psychiatry Service to attend to any risk situation that may occur, including suicide attempts. In addition, professionals from health centers can refer to the Mental Health network through a preferential consultation ”, explains a spokesman.

In the Ministry of Health, which does not have assistance powers, they explain that despite this, initiatives such as the Mental Health Strategy, which has not been updated since 2009, are being added. At the same time, a Mental Health Action Plan was approved in May 2022-2024 co-financed between the communities and the Government, which will contribute 100 million euros. One of its star measures is a suicide hotline (024) that was released that same month and which closed December with 79,975 calls answered, 2,987 referred to 112 and attention to 2,129 suicides in progress or with imminent risk.

Lack of psychologists

It will be necessary to check when the new INE statistics are published if it had an impact on the suicide figures for the second half of 2022. In Hernández’s opinion, measures like these are good, but they represent “a band-aid” in a system that lacks psychologists clinical. “We receive patients who end up leaving the public circuit because they do not feel sufficiently cared for, when they go a month and a half without seeing them, in half an hour they barely have time to tell them what has happened in their lives. Just today a patient told me: ‘You have to go at full speed and you lose the desire to tell anything’. The last straw is that now there are waiting lists even in private ones, ”says the psychologist, who assures that in 29 years of profession she had never worked so many hours a week.

The administrations usually justify this lack of clinical psychologists with a reality: although there are more and more graduates, there is a lack of clinical specialists to cover the positions that would be necessary. The strategy that some communities are adopting is to include non-clinical psychologists in health centers to deal with emotional problems early and try to prevent them from becoming more serious situations.

It is something that Catalonia is doing and that Madrid is studying. The Community announced the incorporation of psychologists in health centers, and is studying what profile they should have. Your Strategic Mental Health Plan 2022-2024 includes an investment of more than 43 million euros and involves the hiring of 370 professional specialists.

While these are incorporated, and in the absence of more clinicians, paying for a consultation becomes the only solution for many patients. Among those who cannot afford it, there are professionals like Hernández who do not charge some, or adjust the rates. “But this cannot be the solution, it has to come from public health,” he stresses.