***Originally published at Mental Health Innovation Network***

Every Tuesday afternoon, my family therapy trainees and I meet to see clients at our university supported family therapy clinic.  Yesterday, Simone,* a woman in her late 40s who was once a legal professional, talked to us about her struggle with osteoarthritis and other chronic health issues. A lively person once surrounded by many friends, Simone now suffers from loneliness, depression, and, occasionally, what she calls her “demons”—memories of traumatic events she experienced as a child. Isolated from her community, Simone is also adjusting to a disability that prevents her full-time employment. Resourceful, funny, and kind, Simone endeared herself to our therapy team as she talked about the many creative things she does to sustain her spirit. Yet every week, Simone has a different crisis. The crisis is often brought on by economic stress, which severely limits her access to the medications her physician prescribed for her in order to stay healthy.

Our next session as a team was with Marcela and her 16 year old daughter, Juana. The family came to our therapy clinic after Juana had been hospitalized several times recently due to her Type 1 Diabetes. She was diagnosed with it at age 6. Now an adolescent trying to find safe ways to explore her independent and engaged mind, while staying connected to her supportive family, Juana has lately been forgetting to take her insulin. She was close to death last month because of it. Juana’s parents are having a hard time coping with this for many reasons. One of them has to do with Marcela’s brush with mortality a few years ago, and the feelings she re-experienced watching Juana go through something much too similar.

We see many types of clients in our clinic. Our questions are specific to each case but in general, as family therapists, we try to understand the systemic nature of the problems our clients bring in to therapy. How do family and interaction patterns influence each other? Can we be helpful in intervening to change this pattern? For Marcela and Juana, we might ask: What is happening in this family with Type 1 Diabetes? What are the beliefs and attitudes about chronic illness, an adolescent girl’s “rebel” identity, and mortality? How do these beliefs shape the behavior of the family? For Simone, we might wonder: What is the pattern of crisis each week that influences her lack of access to necessary medications? What are the challenge she faces to access care? Can we help her close the gap so she can improve the quality of her life?

Access to resources and treatment for psychosocial support is a serious problem faced by numerous people throughout the globe. However, the way it is a problem is not always the same. Individuals and families are vulnerable to psychosocial problems depending on the context in which they live. Obstacles to care may include issues of access to treatment, ongoing conflict or violence, and poverty. In addition, Kakuma et al. (2011) noted that all countries of low and middle income have inadequate funding for mental health, and that “all low-income countries and about two-thirds of middle-income countries had far fewer mental health workers to deliver a core set of mental health interventions than were needed.”

Even where there is the human resource capacity to deliver mental health interventions, such as in the high-income country where I practice, numerous obstacles can exist. Stigma or misinformation about psychosocial issues, or lack of attention to the everyday realities of a client’s life can hinder equitable care.  As one of my students suggested, gaps in mental health treatment are not always about the access to care. In her view, “we must also close a gap in thinking.”

From the systemic perspective we take as family therapists, it is impossible to separate between two types of “health”—one “medical” and one “psychosocial.” Psychosocial health is intertwined with all aspects of health. Juana has to take her insulin to survive. Yet if she does not find healthy ways to be the “rebel” that she wants to be, a “rebel” with a diagnosis of Type 1 Diabetes, her medical problems are likely to recur. Similarly, despite the psychosocial support of our therapy team, Simone, if not able to access the type of medication that is most helpful to her, is likely to go from crisis to crisis.

Mental health needs to be included in the SDGs because mental health and biological health are inextricably linked. While it is true that sometimes the effect of one aspect of our health status is more damaging than other aspects, often this effect depends on the social context. This context includes the community as well as the family. Education about Type 1 Diabetes is important; but so is psychosocial support that addresses the meanings a family ascribes to that diagnosis. Similarly, supporting Simone’s efforts to sustain her spirit are admirable goals. Yet if the effort is not in concert with the larger system, it is not sustainable. So while we work closely with our clients to achieve their goals, we believe strongly that they are not the only person we are working with.  All of us in the community have an investment in improving psychosocial health. We all benefit from closing the gap in thinking as well as the gap in access to care.

*Actual client names have been changed. Their stories have been used with their permission. Thanks to my students for their conversations with me about the SDGs.

Images courtesy of Valentina Iemmi. Copyright © 2014 Valentina Iemmi. All rights reserved