Photo: Arianna Giménez

Barcelona’s Mental Health Plan emphasizes children and young people, as these are the groups most vulnerable to psychological suffering and illness. Barcelona is the only city in Spain and one of only a handful in Europe with a project of this kind. In its first year of existence, over 80% of the Plan’s measures have been applied, especially those focused on prevention and early detection.

Nobody in her family understood what was happening. She had always been a sociable girl with plenty of friends, and she always got good marks. But one day she started saying that she didn’t want to go to school. That she didn’t like it. That nothing in particular had happened, but she didn’t want to go outside. She also didn’t want anything to do with her friends. Faced with the idea of going to class, she would throw up, start trembling and suffer from serious anguish. At the time, she was 14 years old.

Her parents didn’t know what to do; desperate, they sought help at the neighbourhood Mental Health Centre for Children and Young People (CSMIJ, according to its Catalan acronym). “She started suffering from anguish and lots of stress, without any clear trigger. It seems that she couldn’t take in the lessons like she wanted, and it made her shut down”, recalls Luis Miguel Martín, the psychologist in charge of the CSMIJ in Ciutat Vella and Sant Martí, who dealt with her case.

A girl waits for her turn at the Mental Health Centre for Children and Young People (CSMIJ) at the Hospital del Mar.
Photo: Arianna Giménez

It’s likely that the 14-year-old had been suffering for a while before her parents began to suspect anything. It’s fairly common for children to fall silent when they don’t feel well. Often, they won’t say anything out of fear, shame, because they don’t know they’re sick, because they don’t understand what’s happening to them or because they don’t have the language to express themselves, and they somaticize their suffering. “What we did is give her the tools to make it through” notes Martín. “Just like you need to train and build up muscle to run in a marathon, to face certain life situations you have to train every day. So, we gave her a daily plan that even said what time she had to wake up—her schedule had gotten all mixed up, she slept during the day and was awake all night. It included simple tasks and required that she study her favourite subjects. We also gave her medication to help reduce her anguish and her physical symptoms. Now she’s in baccalaureate, and a little while back she came to interview us for the final project she’s preparing on mental health. She’s recovered.”

Just like this young lady, between 10% and 20% of children and adolescents suffer from mental illness according to an estimate by the World Health Organization (WHO). In the case of Barcelona, just in 2014, 10,517 minors were treated for psychological suffering. This number has increased in recent years, as corroborated by the fact that, for example, in 2016 the city’s CSMIJ attended to over 12,300 individuals.

Doctor Luis Miguel Martín, director of application in primary and special programs at the Neuropsychiatry and Addictions Institute (INAD, according to its Catalan acronym), caring for a young user of the Mental Health Centre for Children and Young People at the Hospital del Mar.
Photo: Arianna Giménez

“Half of mental illnesses appear before the age of 18. Many are genetic in nature; this doesn’t guarantee that the person will suffer from the illness, but it is important in determining whether or not they’ll develop it. Environmental factors play a key role. That’s why prevention is so important”, notes Víctor Pérez. Pérez is director of Psychiatric Services at the Hospital del Mar and the coordinator of the Network Centre for Biomedical Research in Mental Health (CIBERSAM, according to its Spanish acronym), part of the CIBER biomedical network, a consortium made up of 25 research groups from eight autonomous communities, with its headquarters at the Carlos III Health Institute in Madrid.

Preventing suffering and mental illness in children and young people as well as in adults is the main objective of the ambitious Mental Health Plan that the Barcelona City Council presented just one year ago. This is a groundbreaking plan in both Catalonia and Spain, and one of only a handful existing in Europe. It will be applicable over the next six years and involves 111 short- and medium-term actions to improve the psychological welfare of the inhabitants of the city. With the plan still in its first year of existence and with a budget of over €50 million, 82% of the included measures have already been successfully applied.

“When we made it to the City Council, we looked at the report prepared by the Public Health Agency with different indicators on health in Barcelona, and we saw that mental health got failing marks. 12% of citizens suffer from a mental illness, ranging from psychological suffering to serious conditions. This number was too high, and we had to do something”, notes Gemma Tarafa, the Council’s health commissioner.

A cross-cutting plan including social measures

As a result, a mental health council was established including, among others, the Barcelona Public Health Agency, municipal political groups, representatives of social organizations working in mental health, and affected families and individuals. For seven months, they worked together to prepare the proposal. “We decided that we needed a cross-cutting perspective, one that wasn’t just medical and health-related; we knew that certain factors like poverty, housing or unemployment also influence people’s mental health”, noted Tarafa.

As a result, the plan includes measures like preventing people from being expelled from their homes and offering social housing to at-risk families, improving the job insertion of groups in difficult socioeconomic situations or fighting against energy poverty.

Children, adolescents and young people are the groups most vulnerable to psychological suffering.
Photo: Arianna Giménez

It places special emphasis on children and young people, the most vulnerable population group. “For two years, we’ve had specific data on minors in the health report, and we saw an increase in psychological suffering from 2012 to 2016. This doesn’t mean that minors suffer from more mental disorders or illnesses, it just means that the conditions they face cause them to suffer more”, explains Pilar Solanes, director of the City Council’s health program. Along the same lines, the report reveals that in districts with more socioeconomically disadvantaged neighbours, there is a higher level of suffering among children than in areas with less poverty.

From suffering to illness

Children are the most vulnerable emotionally because, as noted by Martín, the head of CSMIJ in Ciutat Vella and Sant Martí, they lack the resources to face and adapt to the difficult situations that surround them. They still don’t have the necessary psychological maturity to deal with traumatic experiences like their parents being expelled from their homes, violence against women, migration, unemployment at home or illness.

“We also need to consider abuse of any kind, including humiliation, which is much more frequent in children than we think”, notes Víctor Pérez, who is also a patron of the Mentally Ill of Catalonia Foundation.

This suffering can result in children who don’t sleep, are nervous, who spend their time bothering everyone or who are sad; children who suffer from sometimes-chronic somatic disorders such as pain or intestinal disease, or even severe behavioural disorders that lead to aggression against their parents or other minors. If this mental suffering becomes chronic, it may become a mental illness such as depression. “We need to protect children and adolescents” notes Martín, who explains that CSMIJs attend to more and more young people with self-harming behaviour. “They try and ease the pain or the unrest they feel by harming themselves, like by cutting themselves. It’s not that they want to commit suicide or hurt themselves; it’s that they don’t know how to manage adverse reactions or emotions, they don’t have an emotional education, and they impulsively act this way”, states the psychologist.

A period for building one’s personality

The Barcelona Mental Health Plan puts forth a series of measures aimed at educating people in emotions, and in the early detection of psychological discomfort or mental problems that may affect children, adolescents and young people, always from the point of view of prevention. To this end, for example, a pilot experience has been established at several city schools with the goal of evaluating its effectiveness before it is applied in other schools. It involves a program to educate boys and girls from the ages of 3 to 6 in emotions. “This is the age when they build their personality, and we can help them more effectively if we work preventively”, notes Solanes, who adds that “this age is a critical period for establishing the foundations of good mental health.”

A session of the emotional education program being applied as a pilot test in the Nou Patufet School in Gràcia.
Photo: Arianna Giménez

“It’s all about giving them emotional resources and abilities so they can deal with feelings like anger or frustration, for example”, explains Tarafa. The plan also includes training for teachers, recreational counsellors, cafeteria staff and those working in extracurricular activities so that they integrate emotions into their work. In addition, workshops are planned with families to work on these abilities. Furthermore, in the neighbourhoods with the worst mental health statistics for young people and adolescents, the plan is to provide schools with professionals such as social educators who can give support to teachers, as well as to children with difficulties.

Another measure included in the plan and aimed specifically at adolescents are youth consultation spaces that will be available in 10 of the city’s districts in 2019. These are physical spaces where young people can go to express their doubts or psychological suffering to psychologists, psychiatrists and social educators who, if necessary, will send them to medical centres. One such space in the Marina neighbourhood, known popularly as La Zona Franca, has already proven effective.

“Prevention in adolescents is really important to keep issues from becoming chronic. This is a very important stage in neurodevelopment, critical to avoiding future complications. We need to care for these kids using a service that’s accessible and nearby, to try and prevent their suffering from becoming a mental illness or a significant emotional disorder”, Martín warns.

Promoting job insertion in young people

According to the Barcelona health report, one of the factors that most affects the psychological welfare of young people is unemployment, especially long-term unemployment. As a result, the plan includes measures to reinforce job insertion in young people, starting with those living in the most disadvantaged districts. It also prioritizes the insertion of young people who suffer from poorly-diagnosed mental disorders, such as schizophrenia or depression. In the end, it’s about shifting the bulk of our efforts from the treatment to the prevention of mental illness. “This is a revolution that we need to make as a society. We need to learn to understand what we’re dealing with and manage emotions, both positive and negative (frustration, rejection, rage); we need to learn how to listen to ourselves and listen to others, and to be willing to recognize that they may be right”, advises Tarafa.

“It’s about identifying discomfort, recognizing the symptoms and associating them with an emotional problem. We need to make it a fact of life, and not to experience it as something strange”, Martín states. He adds that this is the only way we can change our current mental health situation.

Born in Madrid 83 years ago, she arrived in Barcelona during the Spanish Civil War. She promoted the first Association of Family Members of the Mentally Ill of Catalonia, and she later founded the Mentally Ill of Catalonia Foundation, which recently celebrated its 25^th anniversary. In 2000, she was awarded the Creu de Sant Jordi for her fight to defend those affected by mental illness which, in her words, “isn’t an issue of yours or mine, it’s everyone’s. It can affect anyone.” In this article, she tells us about her experiences.

Silvestra Moreno, interviewed for this report, who has dedicated much of her life to the defence of the mentally ill.
Photo: Arianna Giménez

“When I got married and had children, I took care of both them and my in-laws, as was normal at the time. One day, my father-in-law –who must have been about 80– started to suffer from senile dementia. He turned aggressive. He thought the neighbours wanted to rob him, that they had broken into his house, and things like that. He reacted violently, so much so that the neighbours were afraid he would hurt them one day. They told me either I got help or they would call the police.

And that’s how it all started. It was 1980. I brought my father-in-law in, and when the doctor saw him, he wouldn’t let me take him home again. They transferred him permanently to the Mental Institute of La Santa Creu i Sant Pau. ‘So, what do I do now?’ I asked. ‘You? Nothing, you’re all set’, they answered. ‘Listen’ I said, ‘I didn’t bring you a package, this is a person. He’s my husband’s father and my children’s grandfather.’ Until he died, I went to see him twice a day.

But the Institute looked abandoned. It was understaffed, and the sick interns weren’t getting the attention they needed. Just a few years before, the administration had begun to close down mental institutions and to return the ill to their homes. People who had been at the institution for 20, 30 years! It was a disaster. They couldn’t get used to it, and neither could the families. And other patients were all alone, without resources. Where could they go?

There at the Institute, I would always talk to the young patients, and most of all I would listen to them. They would say to me ‘I have four children. If one day one of them got sick and I had to bring them here, it would kill me. This place is awful.’ Because of that and because of my father-in-law, I began to get involved. With the support of some professionals, we, the family members, started to timidly make complaints, to protest. Finally, in 1986, I created the Association of Family Members of the Mentally Ill.

As the president of the organization, I was in the know about everything: the patients that died, the ones that were transferred, the ones that were sent home. I was always going to the courts with documents, because only a doctor can take away the right to freedom of an advanced Alzheimer’s patient or someone with dementia, and have them turned over to a mental institution. The public prosecutor recognized what I was doing, and they suggested that the Association take responsibility for the ill who didn’t have families. So, we did. We ended up taking care of 400.

After six years, we decided to go professional. We created the Foundation for the Mentally Ill of Catalonia, which just celebrated its 25^th anniversary. With this association, we basically played the role of the family for the ill. We made sure that no one made decisions about them without taking them into account, either them or their families. We would go and see them and we would show them warmth; we wanted them to know that they weren’t alone and, if they needed anything, we at the Foundation would help them with everything we could. Then, we were given power, something we’re unfortunately missing now. People would listen to us. We organized the second European Congress of Associations of Families of People with Mental Illness. I even ended up as the president of the Spanish Confederation of Groups of Families and Individuals with Mental Illness.

25 years of the Foundation already… I never thought we’d make it this far. I guess it gave me strength to know that mental illness isn’t yours or mine, it can be anyone’s. It’s true that, thanks to our efforts, things have changed a little. At least now we can be sure that people are cared for. When we started out with the Association and the Foundation, there were sick people who only got to see the psychiatrist once a year!

What hasn’t changed much is the stigma. Plus, now there are trends that do a lot of damage. Like saying ‘I’m depressed.’ If you only knew what a real depression is like! The worst part of a mental illness is that the victim themselves isn’t aware that they’re ill, and that means that there’s always a war on in their house. Poor families! Empathy is key. I’ve even spoken with a mentally ill person and her two imaginary friends over the phone to get her to go and see a doctor. Looking back, I remember the faces of many people who were lost and who we found again. We helped them. And that makes me feel good.”

One of every four Barcelonians has a mental health problem. The most common are anxiety and depression; of those that require hospitalization, the most common are bipolarity and schizophrenia. Many of these illnesses begin to appear during adolescence and are genetic in nature. This is the story of Xavier Martí (his real name), born in Barcelona in 1962, who suffers from paranoid schizophrenia. He started to experience episodes of this illness when he was in secondary school, and now he’s cared for by the Mentally Ill of Catalonia Foundation. These lines, in which Xavier summarizes his life, are a powerful testimony.

Xavier Martí at the Ràdio Gràcia facilities, where he has his own program every Thursday afternoon, from 6 to 7.
Photo: Arianna Giménez

“My father would say: ‘my son’s a poet.’ I’ve always liked to read and write. It’s my refuge. And I’ve gotten awards for my poems, even though I haven’t published anything. I was the most brilliant student at my school. It’s not me that says so, that’s what my teachers would say. When I made it to secondary school, I started to feel weird. My big brother, Martín, had already turned aggressive, already had some issues, and he turned against the family. Back then, I held on the best I could. But I suffered a lot. Then I had a self-referential episode, as they call it. Jesus Christ, the greatest exponent of Judeo-Christian tradition, came to see me at home.

Schizophrenia makes you distort things in your head. Still, it doesn’t make you lose all touch with reality, except when you’re in the acute phase; then, you see and hear things that aren’t there, and you get really scared. Trembling, I told my parents; they didn’t understand a thing. So I decided not to say anything. I kept it to myself. Even during military service. I knew that something wasn’t right and I went to talk with the doctor there, but he thought I was trying to get out of military service and he wouldn’t hear me out. People don’t understand you.

When I came back, I couldn’t take it anymore. One day I had a laughing attack and I couldn’t stop laughing. That was when they hospitalized me for the first time. When I got out, I accepted the worst kind of work. I wanted to write, I’m a poet, but the medication left me useless. I worked as a carpenter at a special work centre. I felt really bad. I thought about committing suicide. I tried to throw myself off the balcony at home. Then they changed my medication. All the tests said that I had great potential, but they sent me off to a job washing dishes. A really crappy job.

I have to hang on. I have to be strong. I have to hang on. Now it’s up to me to be a caretaker, for my mother and for Martín. My mother’s getting on in years, and I have to take her everywhere. Martín, who’s 63, suffers from chronic kidney failure and he has to be the centre of attention. He also has paranoid schizophrenia, and plus he’s in the early stages of dementia. I’ve never been aggressive like him, but I’ve been hospitalized twice, and he never has. Go figure.

I have another brother, Toni, who isn’t sick. He loves me a lot. If he sees I’m a little bit nervous, he asks me if I’ve taken my medication. It’s typical. But I can’t get angry, because those of us with a mental illness can’t get angry, because if we do it means we haven’t taken our medication. Toni’s had a really rough time with our situation at home. He’s cried a lot.

What does it matter if it’s genetic or not? At this stage in life… Plus, I won’t have children. But they’ve never analysed my genome. My father didn’t care what happened to me. It was like it was my fault. My mother still doesn’t understand it. For people of her generation, we nutcases aren’t normal people. Someone with cancer is a normal person. But someone with mental illness isn’t normal.

It’s like the judges, who say that I can’t decide who to vote for, as if I was a child. Can you believe it? When I read the court ruling that declared me incapacitated… For the love of God! That really hurt. Until then, I’d never gotten angry with psychiatry.

The second time I was hospitalized, it was like a liberation. That’s when I realized I had a problem; until then, I hadn’t accepted it. My father helped me get recognized as handicapped. I took printing courses at the Joia Foundation and I even worked in a copy shop for three years. Then, my father got cancer and he thought that someone would have to take care of us when he died. He put me in touch with the Mentally Ill of Catalonia Foundation, which takes care of us. They control our finances; they organize activities I participate in, like Christmas dinners, and every now and then I go and have a coffee with the Foundation’s caretakers, who also take me on trips to the doctor.

I like writing. I haven’t published anything, but I have lots of poetry collections. I’ve given writing classes at associations and civic centres, I’ve set up poetic creation workshops, writing workshops in general. Right now, I have four students at the neighbourhood Association of Coll-Vallcarca. I also collaborate with Ràdio Gràcia every Thursday afternoon from 6 to 7.

I used to have friends and even a girlfriend, a girl who loved me a lot and who I was really in love with. When she saw me again after military service, she didn’t want anything to do with me. She married someone else. I don’t want any more relationships with women, I don’t want to suffer. When my school friends started to see some of my issues, they called me crazy and stopped hanging out with me. Nutcase, they’d call me. It’s stigma. It hurts more than the disease itself.

I remember when I worked at a special carpentry centre; a psychiatrist would come and lecture us. He told us we had to get sterilized so we wouldn’t spread our disease. It’s like we have the plague!

Now, I’m depressed again. Like I haven’t been for years. I miss laughing. The political situation also affects me. ‘Xavi, what you’re thinking now, do you really feel it? Will you feel like this tomorrow morning?’, I keep asking myself. But I don’t want any more medication. So, after supper, even if it’s early, I put on the music I like, I take my pills, and I get in bed. I feel so tired…”

Photo: Arianna Giménez

Mental suffering and illness increased in frequency among the population of Barcelona from 2000 to 2016 as compared to previous periods. The unemployed and disadvantaged sectors of society proved especially vulnerable. Mental health problems also affect women to a greater degree.

The information collected in the 2016-2022 Barcelona Mental Health Plan gives us a snapshot of the mental health of Barcelonians. From 2011 to 2016, mental suffering and illness experienced a rise, especially among men aged 18 to 64, where it rose from 11.5% to 16.2%. Nevertheless, this type of health issue continues to affect women to a greater degree, rising from 16% to 18.9% during this period. In this age range, the prevalence of poor mental health in the unemployed is over 25%, and in disadvantaged social classes it is 27.3% among men and 31.3% among women. As for the population over 64, from 2000 to 2016 the prevalence of poor mental health went from 13.5% to 17.6% in men and from 24.9% to 23.8% in women.

If we focus on the two age groups that are considered a priority by the Mental Health Plan, childhood and adolescence, 42% of psychiatric emergencies at Sant Joan de Déu Hospital that took place in 2015 had to do with self-harming behaviour, according to the information presented at the VI Catalan Congress of Mental Health in Childhood and Adolescence, held at the CosmoCaixa in 2017. 9.9% were for suicidal behaviour.

34.4% of doctor’s visits and 36.6% of diagnostics on mental health in children and adolescents have to do with behavioural disorders. 58% of mental disorders in general develop in young people under the age of 12, followed by the ages of 5 to 12, when 39% of these disorders appear. Those affecting children aged 0 to 5 only represent 3% of cases. Up to 30% of mental pathologies in adults are associated with either physical or psychological abuse and abuse suffered during childhood. C.S.