“She diagnosed me with bipolar. She said: You are far too unwell to be able to help yourself. You need pharmacological attention", the psychiatrist at the University of Jordan Hospital told Malak1, 26 years old, after she had a severe panic attack at the university hospital’s ER the day before her appointment with the psychiatrist.
It was the fifth time that Malak had been prescribed psychiatric medication, ever since she embarked on her journey in the world of psychiatrists and psychologists about four years ago. In this world, Malak was given multiple psychiatric diagnoses, ranging from major depression, cyclothymic disorder, multiple personality disorders, and finally bipolar disorder a few months ago. Even at the first session, the doctors and psychiatrists she saw, both in person and virtually, recommended either antidepressants or mood stabilizers.
Malak was afraid of taking medicine and was uncomfortable with the thought of her body and mind being dependent on it without anyone informing her of the benefits of the medication or any potential negative effects. However, every time she saw psychiatrists, she was desperate and unable to help herself without medication.
There is no doubt that many mental disorders and illnesses need pharmacological intervention in order to modify what is known as brain chemistry, but most mental health workers in Jordan agree that pharmacological treatment dominates the list of methods of treating mental disorders and diseases, whether in the public or private sector.
Although many mental disorders and illnesses have biological and genetic causes, they are often triggered by social and economic pressures, and are described as modern diseases of capitalist origin, linked to a deficient definition of health as the ability to work and achieve. However, a lot of patients in Jordan, and in the public sector in particular, are deprived of the integration of complementary therapeutic methods, therefore the most common form of treatment is prescribing medicine.
Missing roles
Psychiatry in Jordan bases its classification of mental illnesses and disorders on the Diagnostic and Statistical Manual of Psychiatric Diseases, issued by the American Psychiatric Association, where 22 psychiatric disorders are classified. But in general, mental illnesses and disorders can be divided into two types, the first is psychotic, in which a person loses the ability to distinguish and discern, detaches from reality, and experiences hallucinations and delusions. Its causes are genetic, biochemical or environmental. The other type is neurotic, in which the person is not detached from reality, but has psychological problems such as stress, anxiety and depression. The World Health Organization classifies mental disorder as an apparent impairment in a person’s cognition, emotions and behavior, usually associated with deterioration or impairment in the performance of daily functions.
"Before the fifties, psychotherapeutic approaches, such as psychoanalysis, were more dominant than pharmacological treatment in the West, says Radwan Bani Mustafa, a consultant psychiatrist at the University of Jordan Hospital. After that, drug therapy became dominant. The treatment of psychotic diseases relied heavily on tranquilizers and sedatives from the nineteenth century until the beginning of the fifties, when psychotic drugs were invented, and then pharmacological discoveries for mental illnesses and disorders emerged and circulated2.
In Jordan, there are no statistics or accurate classifications on the number of people with mental illnesses and disorders, but according to Khaled Al-Hadidi, former director of the National Center for Mental Health, it is estimated that 20% of Jordanians suffer from depression and anxiety. Clinical psychologist Amal Nashwan says these disorders may be symptoms of more serious mental disorders. Specialists point out that the global rate of mental illness and disorders in any society is 25%, and that it applies to Jordan as well. In 2019, World Health Organization stated that one in eight people live with a mental disorder, predominantly anxiety and depression disorders. Estimations showed that anxiety and major depressive disorders have increased by 26% and 28% respectively in one year after the COVID pandemic.
According to most mental health workers interviewed, the best treatment approach, i.e. in an ideal situation, is determined by the specificity of each ailment and the patient’s personality, and by the availability of a specialized team that supports the psychotherapeutic process as a whole, such as a psychiatrist, psychologist, psychiatric nurse, social worker, occupational therapist, in addition to rehabilitation departments.
In the public sector, psychiatric services are available in public, university and military hospitals, in addition to 53 psychiatric clinics distributed in primary care centers, correction and rehabilitation centers (prisons), family protection services, and elderly care centers. Mental health services are provided at these clinics at least once a week, says Nael al-Adwan, director of Health Insurance at the Ministry of Health and former director of the National Center for Mental Health (Fuheis), but in most of these clinics only a psychiatrist and a nurse are present.
On the other hand, integrated psychotherapy services, in terms of providing a psychiatrist, psychiatric nurse, social worker and psychologist, are available in the specialized clinics of the Ministry of Health, such as the Hashemi Shamali Health Center, the psychological consultation clinic near the Sports City area, and the addiction center of the Jordanian Ministry of Health.
Nashwan says that “having a psychiatrist and clinical psychologist to discuss the patient’s situation makes the diagnostic and therapeutic process smoother, and the therapeutic outcomes better for patients”. The doctor may decide, with the advice of a psychologist, whether the patient needs medication or other psychotherapeutic approaches, such as cognitive-behavioral therapy, dialectical therapy, narrative therapy, or psychoanalytic approaches3. According to her, there are depressed patients, for example, who may need pharmacological therapy while others may only need cognitive-behavioral therapy.
Despite the importance of drug therapy, some conditions such as anxiety disorders, obsessive-compulsive disorder, family problems and psychological stress need other psychotherapeutic approaches, according to clinical psychologist Tayseer Shawash. These approaches to psychotherapy are not always available in the public sector and they are expensive in the private sector as a patient may need 8 to 16 sessions. The Ministry of Health did not set a price cap yet for these sessions given that these specializations are relatively new in Jordan, and the price of a psychotherapy session ranges between 50 and 70 Jordanian dinars, according to Shawash.
Selim4, who has been a psychiatric nurse in the public sector for over 14 years, continues: “The psychiatric nurse is essential because he serves as the patient’s liaison with the various medical specialties involved in their care.” In accordance with the requirements of each case, he monitors, assesses, and gives psychological care to patients through nursing interventions. The nurse also creates, assesses, and adjusts the care plan. In addition to administering medication, supervising patients, organizing their files, tracking the progression of symptoms, and coordinating with physicians regarding them, he or she also keeps an eye on the elements of the treatment plan that are being carried out and continuously monitors the patients.
The social worker investigates the patients’ social condition to learn about their social and personal circumstances, whereas the occupational specialist works to increase the patients’ capabilities and autonomy in their daily life, and the rehabilitation specialist teaches patients a profession that allows them to earn money to ensure they feel productive and not a burden on their families or society. Lack of cadres and specialization
Psychiatric professionals say that pharmacologic therapy predominates in Jordan when treating mental illnesses and disorders for a number of structural reasons. These include a lack of mental health specialists in the medical community, funding shortages from the Jordanian Ministry of Health, an emphasis on administrative and bureaucratic procedures rather than the therapeutic process when caring for psychiatric patients, and a lack of interest on the part of the government in the psychological aspect of public health. In many public sector facilities, psychiatric treatment is limited to drug therapy. As per an answer obtained by 7iber from the Ministry of Health, these factors, along with a lack of funding and the migration of specialized staff outside Jordan, are impeding the development of mental health in the public sector.
According to Jordan’s National Action Plan for Mental Health and Addiction for 2022-2026, the number of mental health workers is estimated to be more than 200 psychiatrists, 220 psychiatric nurses, and 130 pharmacists, with less than one psychiatrist per hundred thousand people and 0.13 psychiatric nurses per hundred thousand5. According to the 2018 State of the Country report, issued by the Economic and Social Council, the minimum number of doctors in global standards is 20-30 psychiatrists per 100,000 adults. According to Ayman Mansour, a professor of psychiatric nursing at the University of Jordan, the level of well-being for mental health requires 40 psychiatrists per 100,000 adults.
According to the National Action Plan, less than half of the doctors work for the Ministry of Health, the Royal Medical Services, or universities, with the majority working in the private sector and foreign and local organizations. There is no data available for mental health workers at Jordan’s National Mental Health Centers.
The only job title for psychology graduates in the public sector is “social researcher”, according to the Ministry of Health. According to Mohamed Shuqairat, director of the Jordanian Society for Clinical Psychology, there are no more than five clinical psychology practitioners in the public sector who have a master’s degree and are licensed by the Ministry of Health.
The public sector’s staff shortfall makes providing mental health services a significant problem. According to Mansour, the root cause is essentially an administrative issue and the government’s lack of interest in mental health. There are no privileges for mental health nurses, and there is no job title for a mental health nurse who has completed specialization programs in the Master of Mental Health in universities or specialization programs in the Jordanian Nursing Council, or who has long experience in the field of mental health, where the job title of the mental health nurse remains “legal nurse”.
Furthermore, there is no categorization in the civil service system, therefore transferring nurses between departments and workplaces is equivalent to transferring from one department to another without regard for skill or specialization. According to Salim, a nurse, the Ministry of Health does not recognize the mental health specialist program and does not offer incentives or privileges based on specialization, as evidenced by his personal experience.
According to Salim, in order to give the best nursing care services, there should be one nurse for every five psychiatric patients, as recommended by the Jordanian Nursing Council. However, in certain public mental health facilities, there is one nurse for every 15 patients, or 50 psychiatric patients in others. Nursing care is sometimes limited to handling the distribution of medication.
No time for patients
Sufyan6, 51, was given a schizophrenia diagnosis when he was approximately 20 years old, almost 30 years ago. Given the family history of mental illness and the fact that their older brother also has the same condition, his brother Mujahid acknowledges the need of pharmacological therapy in his brother’s situation. According to Nashwan, individuals suffering from psychotic disorders like schizophrenia require medication intervention as their vision is impaired and speech-based psychotherapy is ineffective, particularly during the acute stage of the illness.
But when his brother needed to be hospitalized for acute episodes of illness, Mujahid hoped for psychotherapy sessions at the National Center for Mental Health – Fuheis, or rehabilitation sessions to teach him a skill, or self-reliance in managing his life after his condition became chronic. Apart from medication, neither Mujahid nor Sufyan mentioned any psychological approaches or therapies that were available at the National Center for Mental Health (Fuheis) at the time.
Consultant psychiatrist Louay Sakr highlights the significant strain on doctors in health centers that provide psychiatric services due to a lack of occupational therapy and behavioral therapy staff, citing the Hashmi Shamali Health Center’s psychiatric clinic, which provides psychiatric services to outpatients four days a week. He sees no less than 40 psychiatric patients every day, and in some cases 100. Despite having a psychologist and a social worker, medical services are limited to rapidly assessing patients and giving medication due to the demand from patients. He says that if he wants to provide psychotherapy sessions, each patient requires at least 45 minutes, which limits his ability to assess and diagnose other patients.
Psychiatrist Najib Fannouna, who retired from the Karama Psychiatric Shelter about a year ago, stated that doctors working at the center are doing their best to provide psychiatric services to patients despite a lack of medical and nursing staff, with only one social worker communicating with patients’ families, if there is any. With no psychology or clinical psychology staff, the doctor’s job is doubled in conducting psychotherapy sessions for patients.
Furthermore, the administrative and bureaucratic processes carried out by medical staff impede the provision of integrated psychiatric care. According to Fannouna, bureaucratic and administrative processes may account for 50% of the center’s total medical activity, affecting the provision of psychiatric care in addition to the issue of personnel shortages.
Because of a shortage of funds from the Ministry of Health and civil society, rehabilitation programs for chronically ill patients at Karama and Fuheis have been suspended since 2008. There was a pottery, glass painting, and other rehabilitation program for chronic schizophrenic patients. These products were sold, and the revenues were given to patients, giving them a sense of productivity and participation in society through their craft.
Under these conditions, Malak has no plans to attend any psychotherapy sessions at the university hospital and is pleased with the support networks of family and friends. “I am past the point where I want to talk. If I need to talk about anything, my friends and support system are there.”
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Translated by Takwa Masadeh
This report is part of a collaborative dossier on mental health in the Arab world, developed by a consortium of media platforms that cover the Arab world: 7iber, As-Safir Al-Arabi, Nawaat, Mada Masr, Mashalla News, Orient 21, and Babelmed.
1A pseudonym at her request and to preserve her privacy.
2History of Psychopharmacology, Annual review of clinical psychology, Joel T. Barslow, and Stephan R. Marder, February 12, 2019.
3The CBT approach is the most used approach in psychotherapy by psychologists in Jordan, according to Specialist Amal Nashwan, it is the easiest to apply and is considered one of the most successful approaches studied in treating many mental disorders. This approach targets the person’s thoughts and cognitive distortions, and working on behaviors that increase the person’s psychological symptoms subconsciously. While the dialectical therapy approach may be used to treat personality disorders, psychoanalysis needs long, continuous sessions and it is expensive.
4A pseudonym to preserve his privacy.
5According to the National Mental Health Plan 2022-2026, the source of these figures dates back to 2019 based on the mental health assessment in Jordan of the World Health Organization’s Mental Health Initiative. In 2022, there were 135 psychiatrists, and in 2023, there were 110 psychiatrists, along with 40 of them working in the public sector. The number of doctors in these years is small, which is less than a psychiatrist per hundred thousand adults.
6*An alias at his request