Image by Noah Schmeling

Op-Ed on Mental Health Services in Lisbon: Stuck Between a Rock and a Hard Place… and the Floor is Lava

Are the boons of socialized mental health services really there for the taking? Is the private option even close to financially feasible? The short answer is, no.

While it is certainly possible to find proper help for mental health emergencies in Lisbon, the road to relief is all too often long and confusing without a roadmap. Atlas Lisboa has tried to shed as much light as possible on how to find yourself safely hospitalized in Lisbon if that’s what you need. Read our article on hospitalization here. Once you’re equipped with the necessary information, come back to this op-ed to hear why you’re not crazy if the system still feels woefully broken and profoundly unhelpful.

An international move is, ideally, an endeavor only taken on in sound, stable mind. That’s surely the case for many of the hundreds of thousands of expats who have decided to live their best and feel their lightest as they rest on their wealth under the Portuguese sun. Many other foreigners however, namely the young and the working class, don’t always have the opportunity – or the means –  to get their head right before leaving behind their families and support systems, trusted family doctors, and in many cases, shared healthcare plans.

Image by Noah Schmeling

This writer knows that the pain and exhaustion of mental health crises are manifold. Poor mental health isn’t only an internal struggle, but a material and interrelational struggle as well. Thousands of miles from home, many of us don’t have the option to move back in with our parents if our mental or emotional states make it impossible to keep a steady job and pay rent; the work must go on, the rent needs to be paid. What’s more, as many immigrants know, it can feel unfair to ask the members of your newfound community and support network to help carry a burden as heavy as manic depression, anxiety disorders, or suicidal ideations. Most communities of working-class newcomers are made up of similarly vulnerable people with their own troubles and limited resources.

In times of crisis, these circumstances lead people to the health care offered by the state or by the private sector. To do so, immigrants, even those on the verge of falling apart, must find their own way to the help they need through the stormy and unfamiliar waters of Portuguese healthcare. Are the boons of socialized health services really there for the taking? Is the private option even close to financially feasible?

Tragically, the short answer to both of these questions is no. While strong, comprehensive mental health assistance is out there to be found, the journey can feel hopeless at times. 

It is important to note that it is not in fact a hopeless endeavor to seek mental health support. If you or someone you know is struggling with mental health and needs help, find our roadmap to hospitalization and enhanced therapy here. Struggling through Portugal’s often frustrating healthcare system is a small price to pay for a chance at a happy, safe, and fulfilling future.

Navigating the bureaucracy of the Portuguese public health system is a frightfully daunting ordeal, especially if you’re still learning the language. It’s practically a rite of passage to collect your own horror story of waiting in one of the city’s numerous public centro de saúde health centers for hours on end, just to be told you’re at the wrong location or took the wrong ticket. Public, affordable healthcare is undoubtedly one of the most attractive motivations for moving to Europe, but in a city as mismanaged and improperly funded as Lisbon, reaping the benefits of socialized healthcare can seem to verge on the impossible. While some of Lisbon’s frequesias (parishes) have properly functioning health centers, many if not most of the centers that service the city’s most immigrant-heavy neighborhoods like Alameda and Martim Moniz are woefully understaffed and congested.

Even once you make it to the right desk, the nearest appointment dates for essential services such as psychiatry or psychology can be months in the future. For people on the cusp of crisis, there is all too often a dire lack of immediate resources. This state of affairs can prove to be not only stressful and inconvenient but outright dangerous, when people in need of serious help might not receive any assistance at all until an ambulance is called to their apartment. In an acute crisis, however, the Portuguese health system does have a 24-hour mental health hotline, reachable at 808-24-24-24.

At first glance, Portugal’s private healthcare system stands in stark contrast to the underfunded and overcrowded public healthcare system. Healthcare groups like CUF and Hospital da Luz have numerous well-equipped and well-staffed hospitals and clinics scattered across Lisbon. These private institutions boast consistently open and flexible appointment schedules for general practitioners, neurologists, psychiatrists, and more. The help is there, as soon as you might need it. The impenetrable red tape and apparently unending waiting lists of the public sector seem to fade away in the face of the well-oiled for-profit healthcare machine. The key term here is, of course, “for-profit.”  The paywalls surrounding these ivory towers of proper mental health care are grossly prohibitive. Psychiatric evaluations and subsequent appointments clock in around 100 euros, general consultations may cost upwards of 130 euros, and internment can come with a price-tag well over 400 euros per day. With prices like these, the almost imminent glory of accessible mental healthcare via the private sector quickly dissipates for a large portion of Lisbon’s uninsured working class.

Many white-collar employers in Lisbon and Portugal at large do, in fact, provide health insurance in their employee contracts, but there is no legislation requiring them to do so. The vast majority of companies in other sectors, such as the restaurant and hospitality industries, in my experience, don’t offer health insurance of any kind. Only worker’s compensation insurance for on-the-job injuries is required by law.

Even if one is lucky enough to land a job that provides health insurance, the depth of these plans vary widely. Some are comprehensive plans that grant significant, no doubt life-changing discounts at most of Lisbon’s private hospitals for everything from dermatology to ophthalmology to psychiatry, bringing triple-digit treatment bills down to less than 20 euros. 

On the other side of the spectrum, the “healthcare” offered by employers can be little more than access to a private mental-health hotline where well-meaning, poorly-paid call center agents suggest you breathe, drink water, and think happy thoughts.

At the end of the day, accessing mental health care in Lisbon is a matter of luck more than anything else. The recent strikes and protests organized by the Union of Portuguese Nurses (SEP), calling for better staffing, better pay, and more vertical career mobility, is a prescient signifier of the sector’s current state of affairs; a more well-organized and better-funded public health care system would benefit both the people it serves and the tireless, heroic workers who make it operate at all. The qualms of the workers are perfectly mirrored by the needs of the citizens, and it remains difficult to put trust in a public health system that is failing to meet the needs of both its operators and its users. 

The private health system in Lisbon and Portugal, as is the case with virtually all private health systems around the world, is a non-option for the uninsured working class. In an era when increasing attention is being drawn towards the effects of financial instability on mental health, to hide some of the only functional mental health resources behind a prohibitive price barrier can seem like a cruel joke. 

The middle space between affordable inaccessibility and luxurious easy access is filled by nothing but a roulette wheel of insurance plans, spun not even by the individual but by the employer. Depending on one’s background and education or lack thereof, even choosing your pick of the lot can become little more than a fist full of short straws. 

As Lisbon continues its fervent path of development towards the interests of investors and affluent newcomers, and away from residents and working-class immigrants, far too many people in need of mental health assistance are falling through the cracks of systems that service few, deny many, and ignore the rest. While luxury boutiques and chic cafes geared towards tourists and idle expats steadily fill in the gaps of Lisbon’s old buildings, the young people and the workers and the immigrant community at large who will sell the clothes and serve the coffees are facing impossibly dramatic hikes in the cost of living and the cost of wellbeing. As wellbeing plummets, anxiety and depression soar to dangerous heights. To continue pursuing our dreams of better lives in the beautiful, soulful city of Lisbon, we need and deserve mental health care that is not either accessible or affordable, but is accessible and affordable.

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