Mental health under scrutiny: Spain lags Europe in psychologists, pay or wait

With six clinical psychologists per 100,000 people, against nearly 18 in Europe, regular therapy in Spain is out of reach for many; the alternative is costly private care. Mental health in Spain has never been talked about so much. Anxiety, depression, stress, eating disorders and emotional wellbeing have moved from often remaining hidden in the private sphere to becoming topics in family conversations, institutional campaigns, the media and social networks. The silence has been broken. The question now is what happens next, when someone decides to ask for help. Spain has around six clinical psychologists for every 100,000 inhabitants, a figure still far from the European average of about 18 professionals. This shortage has direct consequences for care: waiting lists, appointments spaced weeks or months apart, and difficulties providing the continuity needed for effective psychological treatment. This risks entrenching a two-tier mental healthcare system. Those with the means can turn to a private psychologist and be seen every week or fortnight. By contrast, people who rely solely on the public system may face much longer waits. The question is hard to avoid: is psychological care becoming a luxury reserved for those who can afford it? High demand in autumn Autumn is a particularly sensitive time for mental health, bringing a rise in appointments with psychologists. The change of season, steadily shorter daylight hours and the full return to obligations and routines lead many people to seek professional help at this time of year. The underlying issue, though, is that the demand for psychological support has become structural, and many professionals' diaries remain full for most of the year. For psychiatrist Kazuhiro Tajima, founder of APIR, a centre specialising in training resident psychologists, this surge in demand also has a social explanation. "We have never talked so much about anxiety, depression or emotional wellbeing, and that is undoubtedly progress. We have succeeded in making mental health stop being a taboo topic. But the very concept of mental health has also changed profoundly, and that is reshaping what people are asking services for," he says. The shift is far from minor. Traditionally, public mental health services were designed above all to diagnose and treat mental illness. Today they are also seeing a growing number of people seeking professional help tocope with life problems that do not necessarily amount to a disorder. "For decades, mental health services were geared mainly towards treating mental illnesses. Today, more and more people look for help because they are going through situations that are part of being human: bereavement, a break-up, work difficulties, family conflicts or struggles to adapt to particular stages of life," Tajima notes. Even if these situations do not always constitute an illness, the distress should not be ignored. "We must not minimise that suffering, because many of these people can benefit greatly from psychotherapy, from learning tools to cope better with life or simply from having a space where they feel listened to," the psychiatrist argues. Here lies one of the big contradictions in today's debate on mental health. Society has made a huge effort to persuade people to seek help when they need it, yet that greater awareness has not been matched by a similar increase in public resources. "The problem is that the public system was not designed to provide that kind of ongoing support universally. Its core mission has always been to diagnose and treat mental illness. If we now ask it also to absorb a growing demand linked to everyday emotional distress, without structural reform and without extra resources, it is hardly surprising that the system becomes saturated," Tajima warns. And that saturation ultimately affects patients. An appointment every two or three months Psychotherapy needs continuity. Yet the shortage of professionals means many patients seen in the public system have to wait long intervals between sessions, with appointments every two or three months. Clinical psychologist Fran Gullón draws attention to one of the less visible consequences of this lack of staff. Simply getting to see a psychologist is not enough; the treatment requires conditions that allow a genuine therapeutic process to take place. "Psychotherapy is not a string of isolated appointments. It needs continuity, a relationship and time. If we see a patient every two or three months, in many cases we are not really providing psychotherapy: we are doing our best to hold together an inadequate level of care," Gullón explains. The consequences are particularly worrying when an early intervention could prevent the problem from worsening. "This creates a situation we encounter daily in clinical practice: people who need prompt psychological intervention but have to wait weeks or months before they can access it," he adds. For those who can afford it, private consultations become the way to bypass waiting lists and ensure more consistent therapy. For those without such resources, that option simply does not exist. Income thus becomes a factor that can determine not only when psychological care is received, but also how often. In Gullón's view, the discussion about waiting lists should not stop at the time it takes to get a first appointment. "We talk a great deal about how long it takes a patient to enter Mental Health services, and far too little about what happens afterwards. Securing a first appointment is of limited value if the next one is eight or ten weeks later," he warns. Psychologists in short supply The lack of clinical psychologists also appears unlikely to be solved quickly. In the most recent intake, 293 Resident Intern Psychologist (PIR) training posts were offered, just 13 more than the previous year. Although this does represent another increase in specialist training places, the growth is modest compared with the gap that still separates Spain from European ratios. The problem also has a delayed effect. Increasing training places today does not mean instantly having hundreds of new specialists, as future clinical psychologists must first complete their specialist health-care training. Gullón also stresses that raising the number of professionals cannot be separated from specialist training. The PIR system involves four years of specialist health-care training, during which psychologists are trained within the National Health System itself. "We must keep pressing for an increase in the number of clinical psychologists in Spain, in line with society's current needs and converging with the ratios of neighbouring countries," he argues. "If we know thereis a shortage of clinical psychologists, we cannot wait until the deficit becomes unbearable before starting to train more specialists. Every PIR place we fail to create today is a clinical psychologist we will not have in four years' time," Francisco Gullón concludes. A medicalised society Yet increasing resources alone will not settle another major debate opened up by rising concern about emotional wellbeing. The spread of concepts drawn from psychology and psychiatry has helped bring previously silenced problems to light, but it can also encourage people to interpret normal life experiences automatically as disorders. "We must be cautious to avoid medicalising everyday life. Not every bout of sadness is depression, not every worry is an anxiety disorder, and not every difficulty concentrating means ADHD," warns psychiatrist Kazuhiro Tajima. Theboundary between suffering and illness has therefore become one of the key challenges for professionals. In this context, the clinical psychologist points out that one of the current tasks is to distinguish between the suffering inherent in certain life experiences and those problems that require specialist health-care intervention. "We do not need more diagnoses; we need better diagnoses. Above all, we need to ensure that when someone really does require specialist treatment, they can receive it in time," Gullón stresses. "Mental health does not mean never suffering; it means developing the capacity to face life's difficulties and recognising when that suffering has stopped being a normal reaction and become an illness that requires treatment," he explains. No longer a privilege Spain has made huge progress on one of the main challenges around mental health: ensuring that asking for help is no longer seen as a weakness, and that conditions such as depression or anxiety disorders can be discussed openly without the stigma that surrounded them for decades. The next challenge is far more concrete: having enough professionals to care for those who turn to the system. For the psychiatrist and APIR founder, the answer lies in acting on two fronts: increasing capacity and rethinking the model at the same time. "It is essential to boost the capacity of the public system, but also to adapt the model to a social reality that has changed profoundly. Only then will people who genuinely need specialised psychological care be able to receive it at the right moment." Psychologist Francisco Gullón agrees that real progress will come when social awareness is matched by care capacity. "We have achieved something tremendously important: people have lost their fear of asking for help. Now we have to make sure that asking for help actually leads somewhere." In his view, "mental health cannot depend on your postcode or your bank balance. If psychotherapy is indicated, being able to receive it as often as necessary should be determined by clinical criteria, not by money." There is a contradiction that is becoming harder and harder to ignore: citizens are urged to seek help when they need it, but when they finally do so they discover that seeing a psychologist may depend on how much money is in their bank account.