“This year is the last one, if I don’t quit.” “I’m letting my life pass me by.” “It is impossible”. These are some of the phrases that resonated in the head of Claudia Zumel, 29 years old, during the last four years, in which she dedicated time, effort and perseverance to obtain a position as an Internal Resident Psychologist (PIR). And when she took the exam for the fourth time, she got it. “I felt an immense flood of emotions, and I burst into tears,” the young woman tells La Vanguardia.
This year, this woman from Barcelona obtained one of the 247 places offered by the Ministry of Health, for which 3,929 people aspired. This implies that only 6% manage to access this training in the public system. Therefore, it is not surprising that many describe the exam as an “impossible climb” or that they choose to give up and look for other avenues to practice.
“There comes a time when preparation becomes a habit in your routine. “I felt like it was an end in itself and I took it for granted that I had to do it,” says the young woman. Her frustration and disappointment have lived with her in recent years. On several occasions, she considered letting it be, but, at the same time, it became a “personal challenge” that drove her to move forward. It also helped that, year after year, she closed the gap and reduced the number of errors in the 200 questions (more than 10 reserve) that make up the exam.
Although the places for the PIR exam, which is held on the same day as the rest of the specialties, have doubled in the last ten years, professionals assure that they are still insufficient. In fact, clinical psychology has the worst ratio of places per candidate among all health exams.
“We have been anticipating for many years the need, firstly, for more places to be accredited and, secondly, for all of them to be offered, since in some communities this is sometimes not the case,” explains Gabriel Ródenas, clinical psychologist and member of the Spanish Society of Clinical Psychology (SEPC-ANPIR) for Andalusia. “To guarantee minimum structural conditions for clinical psychologists, around 422 PIR positions are needed annually.”
In Spain there are only six clinical psychologists per 100,000 inhabitants, a figure that is far from neighboring countries such as France (15), the United Kingdom (18) or Germany (41). According to the WHO, it would be necessary to triple the number of specialists in the health system than there are currently in Spain, taking into account that the European average is 18.
The lack of places has given rise to movements such as
Claudia has combined her dedication to the PIR with her full-time job all this time. “This has been the hardest. But, perhaps, it has also helped me stay connected and calm.” After eight hours of work, she would rest a little and immerse herself in psychology manuals for four hours until it was time to sleep. “This year I have tried to be more compassionate with myself, and recognize the effort she was making and that, sometimes, we forget during preparation.”
Although the path has been complicated, he has had the support of his family and, especially, that of his father, who is also a psychologist and doctor. “He has been and is a fundamental support in my life, in my preparation and in my short professional career. He is retired and the fact of being able to debate with him and analyze questions together has made it a lot easier for me.”
The lives of many opponents also revolve around the links that are created in virtual communities through platforms such as WhatsApp. “It helped me to read my classmates’ experiences and how they felt. It is a very supportive opposition where a lot of material is shared. I admire all the colleagues who stay at the door every year and I would tell them that if they have energy, don’t stop trying.”
While thousands of students aspire each year to train in clinical psychology, the lack of specialists in health centers has brought to light the shortcomings of the system with overwhelmed professionals, eternal waiting lists, and increased frequency between visits. At the same time, mental disorders are increasingly prevalent, especially among the child and youth population, and the country is experiencing a record suicide rate, surpassing the barrier of 4,000 deaths in the last year.
Beatriz Torres knows hospital saturation up close. She is a clinical psychologist, after achieving her position in the 2006 call, and practices at the Príncipe de Asturias hospital in Alcalá de Henares. In addition, she has trained students at the university and in specialized academies that prepare candidates for the exam. “Public centers in the Community of Madrid have waiting lists of approximately eight months, and the frequency of visits is between three and four months. Would we accept these times with cancer patients who need chemotherapy? It would seem unthinkable, cruel and deficient to us, but in mental health it is normalized.”
And Ródenas, a clinical psychologist in Andalusia, adds: “To be able to apply psychological treatments, time and space are essential, but we cannot do so if a person is given an appointment four times a year.” The lack of specialists also generates a work overload. “I have attended to 14 people in one day with 30-minute sessions per patient,” says Torres, when she worked in another center.
There are a large number of clinical psychologists who, although they have trained in public health, later develop their activity in the private sector. On the one hand, it has to do with the places that are offered, that is, the capacity for replacement and resident loyalty can be “very improved.” On the other hand, the duration of the contracts. “We are chaining temporary contracts of a few months, which make you consider your life project. And, despite everything, we know that not all primary care clinical psychology positions are filled right now,” Ródenas denounces. “There are people emigrating who would like to return to Andalusia, but other communities offer them greater stability and job guarantees.” In fact, this community is at the bottom with 3.5 psychologists per 100,000 inhabitants, according to data from the Ombudsman.
Since assuming her portfolio, the Minister of Health, Mónica García, has expressed her intention to double the number of positions during her term. The General Council of Psychology of Spain (COP) assessed the proposal as “highly positive”, “although there would still be more to do to cover the demand.” Despite everything, the COP warned whether the Autonomous Communities have enough accredited teaching units to be able to attend to this increase.
“It is not just about training them and having specialist positions, but also about ensuring that the system does not devour or burn them. It is no use for us to have specialist positions if the conditions in which we have to do our work are unaffordable and painful,” remarks Beatriz Torres, who combines her work with private practice after years with temporary contracts.
Claudia will begin her residency in a few months with the vocation and reason that led her to study this profession, no matter how “very naïve it may sound”: “to help people.” “Little by little, my motivation developed into something more political.” The young woman believes that psychology should also be a tool for social change, avoiding adapting people to normative contexts that can perpetuate systems of oppression and inequality.
“To paraphrase psychologist Paula Marín: ‘Without social justice, in an individualistic and capitalist system, it is impossible for mental health to be a personal matter.’” Along these lines, the future resident explains that disorders cannot be separated from the context because it is the context that causes, in most cases, that we suffer from them.
The Spanish Society of Clinical Psychology considers that mental health care should be community-based and focused on support networks. “No matter how many clinical psychologists there are, if we do not invest in social policies it will be very difficult for us to help people.” And Torres says: “It seems illusory and perverse to me to try to deposit structural solutions in a therapy space.”
