Mental health: Spain, in therapy | Society | EL PAÍS Whatsapp Facebook Twitter Copy link Comments Patricia Gosálvez - twitter
We are bad. Mental health professionals have never been busier. In Spain, 41.9% of the population have suffered from sleep problems since the start of the pandemic and 38.7% have felt tired or without energy. More than twice as many psychotropic drugs have been prescribed than before, especially anxiolytics, antidepressants and sleep inducers. 35.1% of Spaniards admit that they have cried in the last year and a half. All according to the latest survey by the Center for Sociological Research (CIS). Meta-studies published in international journals offer similar results: cases of major depression and anxiety disorder in the world have increased by 28% and 26% (The Lancet) and post-traumatic stress disorder, anxiety and depression were, respectively. , five, four and three times more frequent than what is usually reported by the World Health Organization (Psychiatry Research).
More and more people are coming for consultation (according to the CIS, 6.4% of the population has seen a mental health professional since the start of the pandemic, 43.7% due to anxiety and 35.5% for depression). What is happening there? What do therapists point out as people narrate their sadness, anxieties, and worries? Based on the clinical histories and the notes taken during the sessions, seven psychologists and psychiatrists, public and private, from different therapeutic schools, explain the anonymous case of one of their patients for this report.
Each one represents symptoms that have been triggered. They tell the story of many others. A nurse on sick leave with post-traumatic stress (14.5% of health workers suffer from a disabling mental disorder and 22.2% from post-traumatic stress since the pandemic, according to studies by the Hospital del Mar, in Barcelona, and the CIBER). A working mother with anxiety (22% of Spanish women declared having had panic or anxiety attacks, according to the CIS). A child obsessed with the virus (52.2% of parents noted changes in their children's behavior). A depressed young man who belongs to the generation that has used mental health services the most. An anorexic, a couple in crisis, a covid survivor...
The wave of mental illness affects us all, although not equally. The blow has been harder for women and young people. People with fewer resources suffer more. And they have fewer solutions: “Many people touched by the economic crisis come to the limited public therapies and they are precisely the ones who have the greatest chance of ending up on medication, since they cannot afford a private therapist, it is a whiting that bites its tail,” he says. Juan Antequera, clinical psychologist in the public. Three times more psychopharmaceuticals have been prescribed to those who identify themselves as "low class" (CIS).
Specialists criticize the scarce attention of the administrations. Spain dedicates barely 4% of the investment in health to mental health (the European average is 5.5% and there are countries that reach 10%) and in the public network there are 11 psychiatrists for every 100,000 inhabitants, half that in France or Germany (the draft of the general mental health law contemplates that there be 18 psychiatrists for every 100,000 inhabitants). Clinical psychologists are even fewer: six per 100,000 inhabitants (three times less than the European average).
“There is a positive part in the fact that so many people have crashed,” says psychiatrist Juan Luis Mendívil: “The pandemic has made visible a mental health problem that was already there, lowering the taboo that existed around it.” In the words of Juan Antequera: "The crisis has allowed us to remove the Instagram filter, it's no longer so embarrassing to come out of the emotional closet." “We will have to see”, he adds, “how long it takes us to forget it”.
Day 1: Pathological grief and major depressive symptoms
Male 71 years old. Patient of Víctor Pérez, head of Psychiatry at the Hospital del Mar in Barcelona.
Mr. X, a restaurant owner and retiree, spent covid at home with his wife at the end of 2020. She got worse: "I'm drowning, I'm going to the hospital." The last time he saw her he was riding in the ambulance. She keeps turning the image over. The woman – together since they were children, a “perpetual courtship” of 50 years, the patient recalls – died three weeks later. The guilt of not having said goodbye torments X.
At first he has a traumatic but adequate duel. However, as the months go by, he does not return to his daily activities. He stops going to the restaurant to help the son who has been left in charge. He also to see his grandchildren: they tire him, they make him uncomfortable. He happens to live alone. He hardly leaves the house in eight months.
His children receive the letter that the hospital sends to the relatives of deceased by covid to follow up on complicated duels. Those of the covid tend to be: because there were no farewells, because they were unexpected deaths, because of the possible guilt complex. [According to a study carried out by the Gregorio Marañón Hospital in Madrid among 300 relatives of covid victims, the incidence of pathological grief was 25%, when the usual rate is 2%.] It's hard to know what normal grief is. For years the DSM-5 diagnostic criteria (the encyclopedia of psychiatric disorders) did not recommend evaluating a grieving patient, but in 2013 it changed: if there is a depressive picture, it should be treated.
The patient, as usually happens with depressive patients, knows that what is happening is not "normal", but justifies it by repeating "And how do you want me to be?". Even so, at the request of the children, it is not difficult for him to go to the consultation. Depressives maintain an important empathy, they listen to others. They also tend to blame themselves for needing help: “If only I had more character, if I were stronger…” says X.
In the evaluation, he meets all the criteria for a major depressive episode, from moderate to severe: sadness, inability to enjoy things in a sustained way for more than two weeks, sleeping poorly, waking up with a lot of anxiety, somatic symptoms such as pain, asthenia , tiredness. He does not have suicidal ideas, but he does lack the will to live. He repeats: "If I don't wake up anymore, nothing would happen", "I think on the street that if I get hit by a bus nobody will miss me". In addition, the patient has a history of depression, at the age of 40, as a result of an economic problem (treated with psychotropic drugs with good results), which makes him especially vulnerable.
Mr. X explains that he spends the day crying, not wanting to do anything, lying on the sofa watching TV but not enjoying it and with a great feeling of guilt: “Now that my children need me more than ever, with the crisis of the hotel trade above, I do not do anything of benefit”. A therapeutic alliance is established to explain to him that there is a medical problem and he begins pharmacological treatment three months ago. Antidepressants and anxiolytics are prescribed (at night, so he can sleep). He goes to consultation every month or two months. The medication will be maintained for at least six months, up to a year. Unfortunately, public health can only offer psychotherapy to very serious cases (resistant depressives, psychotics, bipolar). In milder cases, group therapy can be recommended in primary schools. In this case, with a cohesive family, it will not be necessary. As a preventive measure, mourning groups work well, Barcelona City Council has a program run by psychologists in public libraries to emphasize that mourning is not a disease.
Although the sadness persists, there is improvement. The benzodiazepine acts immediately, a week later he is more active and rested; antidepressants take four to six weeks to work. Mr. X begins to enjoy the grandchildren. He even jokes: "If Barça weren't the way it is, I'd also enjoy a game."
Day 2: Fears and obsessive behavior
Nine year old male. Patient of Mireia Orgilés, child therapist at the Psychological Clinic of the Miguel Hernández University of Elche.
P's mother arrives for consultation during the state of alarm: "The child is not normal." P has an 11-year-old brother and they live in a two-storey house with a small garden. At first he is happy, without classes, he can play all day and spends more time with his parents. Still he develops fears and worries. He asks a lot of questions about the virus and death. Very attentive to the conversations of his parents, he shows an excessive attachment to them. He hugs them tight for no reason, he doesn't want to sleep alone, he gets into her bed at night, he chases his mother around her house and cries if he doesn't find her right away. He previously was not a very dependent child. In general, he is very worried that something might happen to someone, especially his mother, and he is afraid of catching it. He recounts very specific beliefs: he refuses to go to bed without washing his hair because the virus in the air sitting on his hair could pass to the pillow and be swallowed. When they can travel in summer, he does not want to step on the sand of the beach. If they are cleaning a street or a place, he feels that it is a sign of danger and wants to get away. He compulsively washes his hands. In public places he moves chairs with his foot. He asks for gel before and after using the swings. When he goes back to school, he doesn't want to go to the bathroom because there have been others who are not from his bubble group.
In the formation of these beliefs, the first weeks of the pandemic were key. The data was contradictory for all and the children were exposed to the anguish and uncertainty of the parents, the news and internet searches. Children tend to fill in their minds what is hidden from them with content that is even more dramatic than reality itself. We adults knew how to modify our doubts as science advanced, they did not. P does not understand why one day his mother stopped cleaning the grocery store with bleach, or why his father started hugging him without showering when he came home from work.
Added to misinformation is the breakdown of routines, which are basic for minors. They favor their development and their understanding of the world, changing them destabilizes them. The closure of schools prevents contact with their peers and a varied diet. At home, locked up, parental stress translates into greater permissiveness and more incoherence. All day making cakes, he opens his hand with the screens and sedentary lifestyle. Without physical activity, sleep is disrupted. His life is turned upside down.
For seven months, two weekly telematic sessions are held with P. Also with his parents, to give them guidelines. Cognitive behavioral tools are worked with the child to reduce anxiety, such as breathing techniques. There is a psychoeducational phase in which distorted beliefs are counteracted by adjusting the available scientific information to their age: "cleaning is a sign of calm, not danger, because measures are being taken." Automatic negative thoughts are also deactivated by other rational and useful ones (“thinking 'we're all going to get sick' is useless and hurts you”). The informative accompaniment must be prior to the events. For example, explain why masks are removed outside before it happens. Children have been exemplary in its use, much more rigorous than adults. Accustomed to obeying rules, few lower them. It is important to watch that it does not get out of hand.
Sleep habits are also modified: fewer screens, a more active game (even in confinement, playing hide-and-seek or tag at home) and relaxation techniques. The drugs are not recommended in minors.
The sessions are spaced out until P leaves therapy. Her parents are attentive to any alteration in behavior and can consult before a change in measures, such as when masks have to be removed in class, something that is expected to cost many children.
Day 3: Post Traumatic Stress
Woman, 40 years old. Patient of Juan Antequera, clinical psychologist in Madrid public health.
V arrives at the mental health center derived from primary care. She is a nurse in a public hospital, she has been distressed and tired for more than a year, with anxiety-depressive symptoms prior to covid, due to the work situation, the shifts, the impossibility of reconciling (she has two small children). The pandemic triggers it. At the peak of the virus, she shows a lot of stress: she is very self-demanding and is very involved with her patients. She doubles shifts but she feels that the work overload is compounded by the feeling that she cannot do her work with the care and time that she would like. People die around her and she has no ability to act. At the same time, she feels fear and discomfort for her family, whom she fears exposing to the virus and whom she feels has been abandoned. She remembers with anguish how she would put her clothes in a garbage bag and take a shower before touching her children. However, at the height of covid, she was able to function on “automatic”.
At Christmas 2020 she breaks. She has a lot of somatization: generalized pain, inability to rest, emotional incontinence, irritability, uncontrolled crying, attention difficulties. She distrusts herself professionally: "Let's see if I'm going to make a mistake with a patient's medication." The intensity of the virus has slowed down a bit and she asks for a reduction in working hours to compensate for family reconciliation neglected for months. The hospital denies her and tells her that she can go if she wants. That she does not recognize her effort and sacrifices breaks her schemes. She says, "I was born to be a nurse, but for the first time I'm thinking of quitting."
She still she is reluctant to ask for a leave. Like many patients, especially healthcare patients, she thinks that “the strong follow”. She feels guilty for "letting her companions down." But her body can't take it anymore, she advises herself a discharge and her doctor gives it to her.
Her first recommendation is that she V look for a “self-care space”, which does not exist in her life: go for a walk, take a bath, read, meet up with friends... recharge her batteries. She says, "I don't remember what I liked to do when I had time." She starts by doing things like tidying the closets. Something useful, that she doesn't make him feel guilty about. "How am I going to take a walk while my companions are as they are", she repeats.
Although she is achieving small spaces of enjoyment, since she is on sick leave she does not return to the hospital. She is the center of reference for her and her children; she delays or skips important tests, an avoidance tactic typical of her diagnosis: post-traumatic stress. Even thinking about stepping into the hospital makes him relive what happened and scares him.
Post-traumatic stress is common among health workers who have come to consultation after the pandemic. More nursing assistants and nurses than doctors, due to economic conditions and because doctors are taught not to feel much (when you have to give 10 cancer diagnoses a day you end up dissociating). Post-traumatic stress arises from a situation in which the patient feels a real fear, that she does not have to be, but in this case she was also. The symptoms have two aspects. The positive, which produces things: anxiety, fear, anguish. And the negative, which takes things away: the desire, the energy, the hope. The most anxious part produces flashbacks, nightmares; the most depressive part, isolation, inability to feel. Drugs can work for the anxious part, but to "de-traumatize", to relocate, therapy works better.
Almost a year later, V she is still out. She's better, she's less critical of herself, but she still can't step foot in the hospital again.
Day 4: Anxious-depressive picture
Male, 23 years old. Patient of Juan Luis Mendívil, private psychiatrist in Bilbao.
I, a university student, goes to the clinic in mid-2019, pushed by his mother, who years ago underwent psychotherapy for an episode of anxiety that she now recognizes in her son. He begins with a weekly session of eclectic psychotherapy (45 minutes, 93 euros), with psychoanalysis and cognitive behavioral tools, and a dynamic, humanistic and systemic orientation.
He has relationship problems, it is difficult for him to make and keep friends. Feelings of insecurity, some shyness and low self-image, despite being a nice guy, a good person, intelligent and attractive. The perfect son-in-law. He is focused on studies and surfing, his biggest outlet. In addition to the sessions, he begins treatment with anxiolytics.
In a few months, he improves a lot. He already takes very little benzo. We work on interpersonal relationships, he makes friends, he starts going out with a girl. He is in that process when the pandemic arrives and he confines himself to his family (he has an older sister and a little boy). He maintains an ambivalent relationship with his parents and siblings (“I spend a little of them”). This certain degree of isolation with his family and social environment is triggered in confinement. He does not go to class, a space that forced him to interact with others. The distance breaks the relationship with the girl. He has to quit surfing.
He continues with the telematic therapy but develops an anxious-depressive picture, increasing the symptoms, especially depressive ones. For his age group, confinement is a very hard blow, it cuts short all sociability at a vital moment in which it is essential, and they know that personally the virus will not affect them much, which makes the sacrifice harder. The current macrobotellones are a compensation for the prison in which they have been forced to be. Young patients feel that something has been stolen from them. In the case of I: the possibility of improvement when he began to see a way out.
Other patients his age speak of problems finding work or becoming independent and of frustration with the expectations generated. In previous generations, parents educated their children so that they could build a future for themselves. Now they are asked to “be happy”, something much more complicated. In any case, I does not think about the future, nor about the present. Depression prevents it.
Gets worse. He doesn't want to leave the room. He even develops autolytic ideas (“life has no meaning, everything is shit, I'm worth nothing”, he repeats) so the sessions are occasionally increased to two or even three weekly. Antidepressants are prescribed.
The mother is more aware of the problem, the father, more operational, downplays the emotional. She calls him "lazy" or asks him to "wake up." Family interventions are carried out, with the patient's approval, to explain that I's problem is not a voluntary whim, but a disorder. That there is no specific "reason" to be depressed does not mean that it is easy to get out. The patient must feel support and unconditionality. Sometimes it is enough for the parents to be there and remember the temporality of the disorder, “you will not always be bad”. It is important, despite the drink, that they avoid getting nervous. They have to understand that ideas, even suicidal ones, are from the disease, not from I. But they also need to be vigilant.
With medication, therapy and a return to normality, I resumed surfing and contact with friends. Upgrade. He is still a little isolated and feels with envy how others naturally maintain relationships that he finds difficult to create, but he is already in another moment. Continue with the pharmacological treatment that has to be maintained for a few months beyond the symptoms, preventively. I know that he has to stay active in order to be well. He values his own resources, improves his self-image. He is able to say: “I am someone”.
Day 5: Anxiety with somatization
Woman, 38 years old. Patient of Elena Daprá, private psychologist in Madrid.
Or she works as a senior technician, from 8 to 5, plus overtime. She has two children aged 7 and 14, with after-school until 5:30 and a husband, also a senior technician, with a higher position and more income, so the family prioritizes her work. Generally, she is the one who adjusts her shift to look for the children and take care of them in the afternoon.
She arrives for consultation in December 2020. Among her symptoms: headaches, muscle tension, fatigue, lack of sexual desire, upset stomach... Her hair falls out a lot and she sleeps poorly. Her GP prescribes Lexatin. Emotions that he shows during the evaluation: restlessness, lack of motivation, inability to focus on a task, irritability and fits of anger. She feels that she is "angry all the time" or that she suddenly turns into "overwhelming sadness." She has stopped exercising and going out with friends. He goes from having a ravenous appetite to not eating anything. She does not smoke or drink, but many other patients with similar conditions have increased their consumption of alcohol and tobacco.
She or she drags this situation from confinement. Being locked up 24/7 with her family, while she teleworks, makes her feel like she gets up and goes to bed “at night”. She is concerned about the health of her parents and the emotional state of her children. The fear and uncertainty that she feels at the peak of the pandemic do not explode then, but months later. She arrives saying: "Now that Christmas is coming and we are more relaxed, that people are back to normal, I feel worse and I feel like crying all the time... I'm not like that."
The first point to work on her is to explain that she is reacting to an abnormal situation and that this reaction is part of her. Weekly sessions of 50 minutes (100 euros) are established. Given her problems with reconciling (“life doesn't give me”, she repeats) the sessions are flexible so as not to add stress and she can change them 48 hours in advance or do them by Zoom. She insists on the need for self-care: therapy is the first space to dedicate herself to herself.
She arrives with the Lexatin purchased, but like many first-time psychoactive patients she harbors doubts: "I have too much to do to be in a daze," she says. She knows that “something” is wrong with her, but “not enough to take medication”. Although her body reacts by somatizing, she is not aware of her anxiety: "I don't need Lexatin, but more hours in the day." She is told that in the face of an anxiety pathology, the neurons increase their presynaptic opening, so that more nerve impulses pass through, the medication balances them so that she can work at a cognitive level. Anxiolytics are used for specific moments, they will be withdrawn while psychological tools are created. The medication is maintained for three months.
Her main motivation for solving her anxiety is how it can influence her children or "burden" their relationship. Like many women, she overexerts herself at a family and work level. She has cognitive distortions about what others demand of her.
She undergoes a mixture of cognitive behavioral and humanistic therapy, including sessions with phototherapy (in which images are used to project), a session with her husband, and a second phase of empowerment to improve self-esteem. Her irrational ideas about what is expected of her are worked on. She or she begins to delegate to her husband (who agrees with a more equal distribution of tasks) and to her children, whom she allows to be more autonomous. She reviews healthy eating and physical exercise disturbed since confinement. She or she continues teleworking with a flexible schedule, she explains that when she goes to the office she performs less, but she begins to enjoy interacting with her team.
After one year of treatment OR she has overcome her symptoms. The sessions have been spaced every 15 days, and could cease. "This is my space, I don't want to leave it," she says though.
Day 6: Anorexia Nervosa
Female, 18 years old. Patient of the psychiatrist Luis Rojo, head of the Unit for Eating Disorders at Hospital La Fe in Valencia.
Shy, perfectionist and with certain obsessive traits, she N she is hospitalized in the summer after confinement for the third time for anorexia nervosa. She dropped out of school as a result of the pathology that she developed several years ago. Patients who do not respond to outpatient treatment or to the day hospital arrive at the hospitalization unit, an operational resource from 9 to 5, where they have breakfast, lunch and a snack. In the full-time hospital unit, food control is stricter.
Although N is recurring, the waiting list for admissions, currently about 25 people, has been increased lately, especially with first cases. The discomfort generated by the pandemic was a breeding ground. The threatening conditions of a situation that we had never experienced before translated into stress. To this was added the loss of social ties, the limitation of leisure and the increase in idleness, the intensification of family life, with its pros and cons, parental stress... It was also an occasion to think, What can I do to not spoil myself? Many people began to watch what they ate and exercise, which served as a gateway to losing weight for the most vulnerable girls.
N is older than most new cases, where we have seen pups up to nine years old. Some case started on social networks: a group of friends meet to lose weight during confinement; one of them loses control and develops an eating disorder. There are factors of individual vulnerability to enter into obsessive pictures. In a situation with so much lack of control, personalities with perfectionist traits, insecure, who believe they do not have the resources to resolve incidents, see a compensatory way out in the control of their own intake: it is a compensation mechanism. They don't eat to feel better. It calms and motivates them, even if it later absorbs them and they get caught emotionally and biologically.
The income of N lasts only 20 days. Like many recurrent patients, she repeats that she "has lost control again." The previous income had been for four months, a more usual term. It is not recommended to rush the recovery of someone who enters with a body mass index of 14 or 12, or even 11 or 10 (a normal BMI is 18.5 to 26.9), as refeeding can cause problems. At first they gain weight quickly, they arrive empty, but from then on recovery is slow, which helps to contain the phobia of gaining weight.
Earnings like N's were harder during lockdown. They could not receive visits, or go out, or go home for the weekend, great motivators for these girls since income is a loss of autonomy.
On admission, control of diet (and sometimes nutritional supplements) is important but not the only thing. An emotional and psychotherapeutic relationship is established with the patient. Food is there, but it is not what is most talked about during the sessions, two or three times a week. Sometimes it is not easy to communicate, or to recognize that they are sick. "My name is P, I am 11 years old and I have nothing more to tell you," a patient started in a recent session. She said nothing more in the hour that followed. The patients also have sessions with the psychologists, who in turn see their families. Now they are online, something very useful that we have discovered with the pandemic and that avoids continuous transfers to the unit. Group therapy also works; Pharmacological treatment is used when necessary, especially when there are clinical symptoms of depression or psychotic symptoms, to reduce the feeling that they are being watched on the street or on social networks.
N was discharged and has had no further admissions. The evolution of this disease is not bad, 30% relapse, 70% do not: they can continue to feel discomfort, but without it interfering with their lives. Anorexia should not be demonized. Even so, the waiting list has increased and, after the pandemic, it costs more to lighten it.
Day 7: Marriage in crisis
Woman and man. 44 and 48 years old. Patients of Sacramento Barba, couple therapist and mediator of the Atyme Foundation in Madrid.
R and A were dating for five years and four living together before getting married. Without economic problems, they have a boy of 11 and a girl of 9. She is a nurse in a health center, he is a consultant. Like many couples, during confinement they live a kind of parenthesis in which they put all their energies into being well. After a while, the problems that drag from before the pandemic emerge with more intensity associated with an idea: "What am I doing with my life?". It reminds of the vital rethinking that occurs after a serious illness or the death of a loved one. R explains in a session: “I was watching my life go by, not living it, we are becoming more and more different, we cannot continue like this”. Love moves mountains, but in a serious situation, if a couple does not have the resources, it leaks.
In the case of R and A, as in the case of so many couples, the first important change was the arrival of the children. Before they used to travel, they did things together. Later, he works long hours, she only in the mornings, she begins to feel overloaded by the care and begins to reproach that they do not spend time with the family. Durante el confinamiento, por su trabajo, ella se mete en sí misma, apática. “No la reconozco”, repite él en las sesiones. Así llegan al verano de 2020, las primeras vacaciones tras la pandemia. Ambos tienen altas expectativas. Normalmente, es ella quien organiza, pero ahora no tiene ganas y le reprocha a él que no tome la iniciativa. “Con el año que hemos pasado”. Durante las vacaciones, tienen una gran crisis, y dejan de hablarse por no discutir frente a los niños. Él está perplejo: “Cuando ya había pasado lo peor, tuvimos uno de los peores veranos en familia”. Pasan los meses y las relaciones sexuales se paran. A ella no le apetece, no se siente cuidada. Él se siente rechazado. O discuten o mantienen un silencio que ella siente como castigador.
En abril de 2021 comienzan las sesiones semanales de hora y media (100 euros). Se trabaja una comunicación libre de reproches, la exposición de los propios sentimientos y el principio de reciprocidad: los sentimientos de uno están relacionados con los del otro. También que la espiral de reproches y silencios solo lleva a más de lo mismo, es un mensaje de socorro y puede llevar a la separación, que a veces es lo adecuado.
Siete meses después R y A siguen juntos. Acuden a terapia cada 15 días, en breve serán mensuales. Una vez al mes salen solos para reencontrarse. Cuentan que ya se reconocen. Este verano lo han pasado mucho mejor.
