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Discipline, Diagnose & Punish: A Critical Analysis Of Ptsd
Discipline, Diagnose & Punish: A Critical Analysis Of Ptsd
Diagnostication Amongst Syrian Migrants In Jordan
Diagnostication Amongst Syrian Migrants In Jordan
Erik Kramer
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Recommended Citation
Kramer, Erik, “Discipline, Diagnose & Punish: A Critical Analysis Of Ptsd Diagnostication Amongst Syrian
Migrants In Jordan” (2020). Yale Medicine Thesis Digital Library. 3925.
https://elischolar.library.yale.edu/ymtdl/3925
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1
Discipline, Diagnose & Punish: A Critical Analysis of PTSD Diagnostication amongst
Syrian Migrants in Jordan
A Thesis Submitted to the
Yale University School of Medicine
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Medicine
by
Erik James Kramer
2020
2
Diagnose, Discipline & Punish: A Critical Analysis of PTSD Diagnostication amongst
Syrian Migrants in Jordan
Erik Kramer, Catherine Panter-Brick, Aniyizhai Annamalai. Department of Psychiatry,
Yale University, School of Medicine, New Haven, CT.
This qualitative project seeks to explore sociopolitical factors influencing post-traumatic
stress disorder (PTSD) diagnostication in Syrian migrants living in Jordan. Interviews
were performed with twenty-three key informants, comprised of clinicians,
organizational staff, and scholars, using semi-structured techniques which were analyzed
with grounded theory analytic approaches. The results illuminate the complex social
forces governing the practice of PTSD diagnostication in the Syrian migrant population
in Jordan, with a focus on the effects of financial pressures. This is the first study to
report extensively on the financial pressures affecting PTSD diagnostication in this
setting. These data served as rooted substrate for a critical theory-informed secondary
analysis through the dyad of Foucault’s concept of the carceral archipelago and the
concept of abolition geography from black radical scholarship. The analysis suggests that
the phenomenon of overdiagnostication of PTSD in Syrian migrants represents an
instance of both totalitarian and colonialist instrumentalization of psychiatry.
3
Acknowledgements
Funding for this work was provided by the Yale University School of Medicine, the Yale
University MacMillan Center, and the Yale University Department of Anthropology. The
contributions of Andres Barkil-Oteo and Rana Dajani are acknowledged for their insights
into the complexities of trauma and guidance on conducting research in Jordan. The
knowledge and patience of the many interviewees and their contacts were invaluable to
this project.
4
Table of Contents
Title Page 1
Abstract 2
Acknowledgements 3
Table of Contents 4
Key Terminology 5
Introduction 7
Methodology 12
Results 15
Discussion 30
References
Appendix A
49
53
5
Key Terminology
—
Asylee: an individual who is seeking international protection. In countries with
individualized procedures, an asylum seeker is someone whose claim has not yet been
finally decided on by the country in which he or she has submitted it. Not every asylum
seeker will ultimately be recognized as a refugee, but every recognized refugee is
initially an asylum seeker.1
—
Displaced person: persons who have been forced or obliged to flee or to leave their
homes or places of habitual residence, in particular as a result of or in order to avoid
the effects of armed conflict, situations of generalized violence, violations of human
rights or natural or human-made disasters. This is an umbrella term which is agnostic
to a person’s immigration status and includes undocumented migrants, refugees, and
asylees.1
—
Inter-Agency Standing Committee (IASC): an inter-agency forum of UN and non-
UN humanitarian partners founded in 1992, to strengthen humanitarian assistance. The
overall objective of the IASC is to improve the delivery of humanitarian assistance to
affected populations.
—
International Medical Corps (IMC): a global, nonprofit, humanitarian aid
organization dedicated to saving lives and relieving suffering by providing emergency
medical services, as well as healthcare training and development programs, to those
affected by disaster, disease or conflict.
—
Institute of Migration (IOM): a leading inter-governmental organization in the field
of migration which works closely with governmental, intergovernmental and non-
governmental partners.
—
Mental Health and Psychosocial Support (MHPSS): any type of local or outside
support that aims to protect or promote psychosocial well-being and/ or prevent or treat
mental disorder, with an emphasis on layered system of complementary supports that
meets the needs of different groups.2
—
Migrant – An umbrella term, not defined under international law, reflecting the
common lay understanding of a person who moves away from his or her place of usual
residence, whether within a country or across an international border, temporarily or
permanently, and for a variety of reasons. The term includes a number of well-defined
legal categories of people, such as migrant workers; persons whose particular types of
movements are legally-defined, such as smuggled migrants; as well as those whose
status or means of movement are not specifically defined under international law, such
as international students. At the international level, no universally accepted definition
for “migrant” exists. This is the term that will be primarily used to described Syrians
living in Jordan, as they represent a mixture of asylees, refugees, documented
migrants, and undocumented migrants.1
6
—
United Nations High Commission for Refugees (UNHCR): a United Nations agency
with the mandate to protect refugees, forcibly displaced communities and stateless
people, and assist in their voluntary repatriation, local integration or resettlement to a
third country.
—
Refugee: a person who, owing to well-founded fear of being persecuted for reasons of
race, religion, nationality, membership of a particular social group or political
opinion, is outside the country of his nationality and is unable or, owing to such fear,
is unwilling to avail himself of the protection of that country; or who, not having a
nationality and being outside the country of his former habitual residence, is unable
or, owing to such fear, is unwilling to return to it. In technical usage, it refers to
someone who has been granted refugee status by UNHCR.1
7
Introduction
Neo‐colonialism is… the worst form of imperialism. For those who practise it, it means
power without responsibility and for those who suffer from it, it means exploitation
without redress.
Kwame Nkrumah (1965)3
I. Background
The Syrian war and the resulting displacement of Syrians has had a profound impact on
the mental health of Syrian refugees. The United Nations High Commission for Refugees
(UNHCR) has stated that the most prominent medical issue facing Syrian refugees (where
appropriate, hereafter referred to as Syrian migrants, a more inclusive term than the
colloquially used term “refugee”) are “emotional disorders” of various kinds including
post-traumatic stress disorder (PTSD).4 Simultaneously, it has long been recognized that
categories of psychological pathology are frequently distinct between Western and non-
Western cultures.5 This is particularly true for those diagnoses which are heavily influenced
by the ebb and flow of social, political, and cultural contexts such as PTSD.6 Specific
sociocultural factors (e.g. linguistics, traditions, collective experience, explanatory models
of disease) are known to diminish clinicians’ abilities to accurately diagnose mental illness
in non-Caucasian populations, and can alter disease progression and outcomes.7
Broadly building untested, Western-centric assumptions into psychiatric
diagnostication and care of Syrian migrants has poor construct validity at best, and at worst
is disenfranchising and psychologically damaging. Recent scholarship within the
transcultural psychiatry literature by authors such as Barkil-Oteo and other have called into
8
question the validity of epidemiological studies which estimate that 30-50% of Syrian
refugees meet criteria for PTSD based on Diagnostic and Statistical Manual 5 (DSM-5)
standards.8,9 This point suggests that there is indeed a fundamental gap that exists between
published research on Syrian trauma and the lived experience of Syrian trauma. There has
been limited research to illuminate the borders of Syrian migrants’ explanatory models for,
and the discourse around psychological trauma. According to Quosh, “despite calls for
culturally sensitive and locally grounded mental health research, only a few studies
regarding Syrian mental health have sought to understand how Syrians who have survived
war and displacement personally interpret their immaterial needs.”10
In light of this, an initial research proposal was created with the goal of
investigating the ontological formations of psychological trauma in Syrian migrants. This
initial project was envisioned as a collaboration between the authors and several medical
professionals affiliated with Hashemite University in Jordan who would conduct the
interviews with Syrian informants, organized by a non-governmental organization (NGO)
called the Collateral Repair Project based in Amman, Jordan. After approval and five initial
interviews, it became clear that some of our research associates in Amman lacked the
theoretical background and ethnographic skillset to appropriately conduct the inquiry as
designed. Interviewee well-being was also a serious concern, as it rapidly became clear
that the interviews were distressing for both the interviewees and interviewers. Although
the participants consented and were generally enthusiastic about participating, our team
did not feel that the conclusions of the inquiry would be worth the emotional toll extracted
from the participants. Parallel to this development, an interesting subject arose in our
conversations, focusing on the various structures and pressures present within
9
internationally operated clinics encouraging clinicians to give Syrian migrants mental
health diagnoses. I was particularly sensitized to this topic because of my interest in making
use of transformative-emancipatory research paradigms which preferentially attend to
issues of power and equity. As a result, it was decided to shift the focus of the inquiry
towards a more sociological investigation of how PTSD diagnostication was being
practiced in international non-governmental organization (INGO) mental health clinics.
The new participants, which included practitioners, managers, and clinic staff were deemed
to be a far less vulnerable population and fell within the purview of our Yale University
human subjects committee review as well as the institutional review of our partner
organization in Jordan, the Collateral Repair Project.
The malleability and apparent inapplicability of the PTSD diagnosis in the Syrian
population naturally lead to questions concerning the instrumental utility of the diagnosis:
who is making use of the diagnosis, under what circumstances, and why? The new aim of
the study therefore sought to understand the factors influencing the use of the PTSD
diagnosis from the perspective of organizations involved in the provision of mental
healthcare services for Syrians in Jordan.
II. Theoretical Approach
It has been recognized that “trauma studies related to the MENA (Middle-East and North
Africa) region is not only an emerging field in the humanities and social sciences, but also
a political and social field of manifold struggles over power and dominant regimes of
truth.”11 Much has been written regarding the instrumental use (sometimes called
secondary gain) of mental health diagnoses by migrants and other victims of violence
10
particularly in Palestine, as a means of gaining rights. In a seminal work, Didier Fassin
lucidly characterized what he calls the new “moral economy” of the 21st century, wherein
victims of trauma use diagnostic categories to call for justice and substantiate asylum
claims through the process of political subjectification (becoming subjects with agency as
opposed to objects).12 The established discourse surrounding this process, while complex,
is broadly written about in a positive light, as it is currently understood as a method of co-
producing agency for subaltern individuals. The present research sought to investigate how
diagnostication occurs, and whether the ecology of the practice confirms or contradicts the
established narrative that clinically documenting trauma is universally a rights-granting
activity. In other words, is the malleability of the PTSD diagnosis (and other mental health
diagnoses) mobilized for instrumental purposes by actors other than the clients themselves?
In the following, I present a case for reimagining the diagnosis of PTSD in Syrian
migrants within Foucault’s biopolitics framework as an entity which instead serves the
interests of states, INGOs, and the mental health profession in Jordan. Foucault’s
formulation of biopolitics and the carceral archipelago in Discipline and Punish provides
a useful scaffold for conceptualizing this alternative narrative.13 There is at once the
creation of “docile bodies” within Syrian patients, subjected by the power of both INGO
mental health clinics and state-governed immigration regimes, and “docile bodies” within
mental health providers as they are influenced by streams of thought within Western
psychiatry and international funding channels. These forms of control represent
manifestations of a carceral archipelago which I argue limits the mobility of Syrian
migrants into the Global North and governing the discipline of mental health in Jordan.
Given this analysis, I ultimately argue that such use of PTSD constitutes a process
11
consistent with two categories of psychiatric instrumentalization defined in the literature—
colonial and totalitarian instrumentalization. Finally, I make use of scholarship from the
black radical tradition to consider how the concept of abolition geography and the critical
reappraisal of time can help subaltern communities imagine ways of collectivizing, living
democratically, and evading state-sanctioned misrepresentation.
This research inquiry was informed by a transformative-emancipatory framework,
with an explicit focus on questions related to and arising from issues of power and equity.14
In effect, our study became bi-phasic because of the unforeseen challenges as described in
the introduction. We allowed participant and community-informed feedback to redirect and
refine the inquiry. This research approach lends potency and validity to the study, and in
theory, dissolves the boundaries between research, advocacy, and community
development.15 As prior authors in transcultural psychiatry have done, we adopted a
critical-interpretivist approach which reflects the nature of organizations and their
members as socially constructed, while maintaining an awareness of our positionality
within the researcher-subject dynamic, allowing the project to “a process of invention and
intervention and of co-construction between the researcher and the researched.”14
12
Methodology
I. Study Design and Sample
The Collateral Repair Project (CRP) was founded in 2006 by two American women in an
effort to counterbalance the devastating impact of displacement caused by the Iraq War. It
serves as a community center and provides emergency assistance and programming for
displaced persons living in Amman, Jordan. As a community hub for Syrians living in
Amman, it was an appropriate site to reach an adequate number of key informants. This
research is intended to be hypothesis generating, rather than conclusive. Therefore, a target
sample size of 10-20 informants was established to achieve theoretical saturation. In total,
23 interviews were conducted; further details about these informants are provided in the
results section. Qualitative interviews were carried out with key informants who were
identified by snowball-sampling until no new thematic information arose during interviews
(theoretical saturation). As described, the initial phase consisted of five interviews with
Syrians displaced to Jordan as a result of the Syrian War. These initial informants were
beneficiaries of CRP, and were not professionals in healthcare or humanitarianism.
Following this initial phase, new inclusion criteria were established: informants of any
nationality, age, gender, or profession who are working or had worked in any capacity on
behalf of beneficiaries that included Syrian migrants. The only exclusion criterion was
Syrian migrants not currently or previously acting in roles related to the delivery of services
to other Syrian migrants. Because no inclusion or exclusion criteria were established based
on other demographic information, this demographic information was not collected. No
official screening process was used to identify key informants. Key informants included
13
organization managers, clinic directors, clinical consultants, psychiatrists, social workers,
and academic faculty. A semi-structured, eight question interview guide was developed
with the assistance of Yale faculty in the Anthropology and Psychiatry Departments for
use in the interviews (Appendix A). The interview guide also included several “warm-up”
questions and between zero and nine prompts for each of the eight questions. Interviews
were conducted with the assistance of an Arab-language medical interpreter when
appropriate.
Human subjects committee approval (#2000023921) was obtained from Yale
University, and from the institutional review board at the Collateral Repair Project which
served as our organizational research partner registered with the Ministry of Social Welfare
of Jordan.
II. Data Collection
From October 2018 to December 2018, three researchers trained in qualitative research
methods conducted twenty-eight individual interviews with key informants. Interviews
were recorded on a HIPAA compliant device which was kept locked at all times. Interviews
were transcribed verbatim and uploaded into Nvivo for analysis. One researcher (EK)
reviewed the transcripts and used the constant-comparison and grounded theory (inductive
reasoning) approaches to data synthesis.16
III. Data Analysis
Data analysis was conducted by EK using the standard constant comparison method.17-19
On completion of coding and reaching thematic saturation, the coded data were organized
14
into a conceptual taxonomy, and themes were developed and applied. Nvivo 10 was used
for analysis (QSR International, Melbourne, Australia).
15
Results
Key informants included 5 displaced Syrians in the initial phase. The second phase
comprised of 2 organization directors and managers, 3 clinic directors, 2 clinical
consultants, 2 psychiatrists, 5 social workers, 3 academic faculty, and 1 legal scholar, for a
total of 23 interviews. The average length of the interviews was 52 minutes. At thematic
saturation, fifteen themes were synthesized which were then organized into eight domains.
These domains are: ambiguity of client histories, clinical criteria, client agency, state of the
profession, financial incentives, problematizing cross-cultural diagnostication, and co-
constructing images of the migrant.
Domain 1: Ambiguity of client histories
One aspect which clouded the ability of practitioners to make assessments in their clinic
was the ambiguous clinical histories of the patients they saw. Many displaced Syrians came
to Jordan with medications and diagnoses and few records. Some patients were able to
articulate their clinical histories, but others attended their appointments with empty bottles
of medications or nothing at all.
There are few re-assessments going on. So if you make this diagnosis then it will
be attached to this beneficiary forever. It is complicated though because some of
them received a diagnosis from a doctor in Syria, and it’s hard to account for what
is causing their symptoms – is it that they have the disorder, or from the meds they
were receiving in Syria, or is the effects of the war or their current situation that is
making the symptoms occur?
The fact that case formulations from previous clinicians created prior to flight from Syria
lends itself to a certain malleability of present case formulations. Without prior histories,
it is difficult to remove diagnostic labels from their files.
16
Domain 2: Clinical Criteria
2.1—Conflation of effects of conflict with present context
Almost all informants discussed this theme at length: many felt that the clients being seen
in their clinics were suffering from psychosocial stressors much more related to their living
conditions and liminality rather than from direct aftereffects of their experiences with the
conflict and flight from Syria.
They are suffering indirectly [from the conflict]. What I mean by this is the family
conflict, the economic situation, and this is indirectly related to the war because
they lost their property, their job, and their social network and sources of support.
Another provider expanded on this idea:
They are still suffering from some issue in their life like family conflict, sometimes
depression, sometimes anxiety but it is not related to the war and displacement,
because they can adapt with that, but it is something related to their history, most
of the patients from when they were a child [sic] and is not directly related to the
war. Maybe it is not expected to say that, but this is in reality what I see in the
clinic. Most of them do not come to the clinic because they are suffering from the
war. Most of them are suffering because they had poor treatment when they were a
child, and from the economic situation in Jordan because most of them are suffering
from the hard-economic situation, they have no good education for their children,
no jobs for the men, they are not allowed to work, they don’t have access to work,
and this issue impacts on them psychologically.
2.2—Self-fulfilling prophecy of pathology
Many informants described how the clinical environment in Jordan was arranged to
excessively pathologize the mental health of displaced Syrians. At a systems level,
informants related this to what they believe is a Western predisposition towards viewing
all Syrians as being traumatized.
There is increased PTSD partially because it is almost obsessively looked for in
these populations, so it is a self-fulfilling prophecy… In reality in the clinic what
17
we find is that it is 3-4% of people who actually have the disorder and need follow-
up which is more reflective of reality.
Thus, when clinics and health systems are informed by this tendency to look for higher
incidences of PTSD, the informants felt that higher rates would be “found” and
documented. A high-level director explained that, “if you look at after arrival, basically
there is no difference in rates between the host population and the refugee population,
except for a very slight increase in PTSD.”
The prior discussion hinged on criteria being used to make a dichotomous decision
about the client’s status: disease present or disease absent. Informants also used disease
severity as a lens to view the issue, giving the discussion more granularity.
In my perspective, many of these diagnoses can be seen in a different way and be
treated differently, without psychotropic medications. The severity of the problem
is not often taken into account.
Informants said that while for many clients, there were symptoms present which could
fulfill the majority of clinical criteria for a diagnoses, but that the universal requirement
that “symptoms create distress or functional impairment (e.g., social, occupational)” was
often not present or too mild to qualify:
For example, for mild or moderate cases, they could often be treated with non-
pharmaceutical approaches like counseling or therapy or other supports, more
psychological intervention or psychosocial support.
Notably, European and American informants used more veiled or diplomatic
language to describe what they felt were inappropriate diagnoses: “Quite a good number
of diagnoses that I see, can be… viewed in another way. I think there are many diagnoses
that are maybe not appropriate.” In contrast, their Jordanian colleagues were often much
more forthright about the same sentiment.
18
Domain 3: Client Agency
3.1—Addressing clients demands for receiving diagnoses
Several informants who worked directly with clients clinically or to prepare their dossiers
for application to the migrant resettlement system described encounters which sometimes
felt adversarial, with clients demanding the receipt of diagnoses. Informants explained that
these demands are rooted in the belief that having a mental health diagnosis like PTSD
would be helpful for their resettlement claims.
There is a good number of clients who come to the clinic and demands a psychiatric
report to put into UNHCR [sic]. They think that it will be very helpful for them to
be resettled outside of Jordan which is not true. They are not going to take
somebody who is suffering from low mood and suicidal ideas, “we don’t need you.”
Of course, they want families who can build, not to go to Paris or to Madrid to be
admitted to a psychiatric hospital. Sometimes it is my job to clarify for the clients
this point.
Another informant described how these adversarial encounters could sometimes escalate
very quickly, to the point where clients would endorse suicidal ideation, interpreted by the
informants as conspicuous threats:
And there are some cases where, especially young women, who have a very strong
reaction and come to UNHCR and say “I will commit suicide unless I am
resettled.” So it reinforces this pattern. So now we only do the assessment if
UNHCR asks us for the report. But even when we do this it is very synthetic, we
don’t give very much detail and it is very superficial.
3.2—Diagnosis as organizing concept
Simultaneously, however, many providers also explained that other clients who sought
these labels did so for therapeutic purposes. Possessing a diagnostic entity to affirm or
validate their lived experiences can be useful for their healing.
They explain that it is very useful for them to differentiate between the cognition
and healing and the body sensation. They feel that sometimes they say like, I get it
19
now and I find what is the resource of my disorder, when I can label all this I can
understand myself more.
There thus exists a tension for providers between providing artificial diagnoses to clients
who appear to be seeking diagnoses for external goals (secondary gain), and those who are
consciously or sub-consciously searching for a diagnosis as a central organizing concept
to explain the phenomenological manifestations of their mental distress. In some clients,
providers described that both goals could be present at once. Navigating these tensions are
an added layer of complexity for providers in this context.
Domain 4: State of the profession
4.1—They don’t believe in psychiatry
In conversation with a Jordanian psychiatrist about why many Jordanian medical students
avoid training in psychiatry, they responded that many medical students and “doctors
maybe don’t believe in psychiatry” in Jordan. As for patients afflicted with mental health
disorders and their families, psychologists and psychiatrists are typically seen as last
resorts.
Most of the clients will visit a psychiatrist at the end of his suffering, after visiting
imam, family [sic]. It is a last resort. Why? Because at the beginning most of their
families and they don’t believe in psychiatry as a specialty.
Informants explained that this reflects both the strong filial responsibilities expected and
practiced by their clients and their families, as well as the novelty and otherness associated
with psychiatry, which they are often unfamiliar with. Informants also said that students
feel that the reimbursement for psychiatry is much lower than in other specialties: “they
think that maybe in the future even if they open a private clinic, they won’t gain money, as
much as surgeons or obstetricians.” They explained that the residency for psychiatric
20
training is the only training program in which residents must pay tuition to complete the
residency. Informants felt that these issues stemmed from societal and governmental biases
about the legitimacy of psychiatry in Jordan, which propagate the difficulties of practicing
in the country.
Some informants believed that due to these many barriers in pursuing psychiatry,
the quality of training is quite poor in the country. This then catalyzes a vicious downward
cycle delegitimizing the specialty. One European informant connected this training quality
with the process of over-application of inappropriate diagnostic criteria, both in their NGO
and throughout the country:
This is the way [this NGO] is working but also because this is the way Jordan is
working. I think this is related to the quality of training for psychologist and
psychiatrist which is quite low in Jordan.
4.2—Monopolized power to change diagnoses
In Jordan, only licensed psychiatrists are able to officially make mental health diagnoses,
to change them, or to remove them from a client’s record. Non-psychiatrist informants
universally felt that this was problematic for their practice in several ways. First, they felt
that it leads to an overemphasis on medicalized pathology over psychosocial pathology,
pushing many clients unnecessarily towards pharmacological treatments rather than
psychosocial interventions.
In Jordan only psychiatrists can give diagnosis, psychologists cannot, things are
often medicalized [sic]. What I mean by this… So a beneficiary will first see a case
manager who will decide what needs to happen next, then they will see a
psychiatrists who will give them a diagnosis always, then their plan will be followed
by the team in terms of the goal and objectives. Most of the beneficiaries they will
receive a mental health diagnosis.
21
It is important to note in the excerpt above, that the informant twice emphasizes that the
psychiatrists that they worked with will “always” give a diagnosis and that “most”
beneficiaries will receive a diagnosis. It was clear that the informant felt that this diagnostic
monopoly, in addition to contributing to over-reliance on pharmacological interventions,
was a contributor to the overuse of diagnostic criteria.
Other informants shared this perception. They felt that there were many more
Syrian migrants being diagnosed with mental health disorders including PTSD than was
needed or appropriate. However, they felt powerless to change the diagnoses because they
required a psychiatrist’s approval to do so. One informant said:
For me, this [patient did not have] psychosis, and I couldn’t negotiate with the
doctors… and they said, “Yes but they have the symptoms.” And I said, “Yes but
these symptoms do not equate with a diagnosis!”
This was seen as a reflection of the profession of psychiatry in Jordan attempting to
consolidate its control over the larger field of mental health which includes psychologists
and other mid-level providers. This diagnostic monopoly helps regulate how and where
reimbursements are directed.
Domain 5: Financial incentives
5.1—Achieving diagnostic quotas
Several providers working for INGO mental health clinics stated that they often felt
pressured by their managers to meet target numbers for mental health diagnoses. In other
words, if they were not giving out enough diagnoses within a given timeframe, they would
be encouraged to increase their numbers to meet a pre-established quota. The majority of
22
informants readily acknowledged the tension between diagnostic quotas and the low
prevalence of PTSD seen in their clinics.
Yes, most of the clients must not be diagnosed with PTSD [sic]. Not most people in
Syria or Iraq must have PTSD. It must just be symptoms that do not meet the criteria
of the disorder. It might be reactive depression, it might be anxiety. But it [the
diagnosis] is important for the organization or the people who give us the funds.
They concentrate on the target of clients. It is very important for them to meet a big
target of clients for the funds…. for some clients, honestly there is no need to open
a file for them.
Several providers independently stated that their clinics received $100 USD from UNHCR
for each new diagnosis that they made. This reimbursement was higher than what was
received for seeing clients for follow-up visits, leading to a managerial preference to see
new clients. Another informant described how this pressure created a temporal tension
between funding bodies’ requests and the realities of making clinical diagnoses:
They [donors] want diagnoses in the first session; they cannot understand it
sometimes takes longer to make the diagnosis. So, I say “Ok, if you need to know
the diagnosis I will give you my first impression, but I cannot make a full diagnosis
at this time.”
Informants also described another factor informing how clinics respond to their
financial constraints. Donors (such as private foundations and governmental grants) are
typically tied to one to two-year funding cycles. This short cycle length encourages donors
to force clinics to collect and report on short-term indicators (e.g. how many sick patients
seen, how many initiated on pharmacotherapy), rather than what they felt are more relevant
longer-term metrics like symptomatic resolution and social functioning.
The pressure to make additional diagnoses was differentially sensed at different
organizations. Larger, better funded organizations operating at larger economies of scale
appeared to apply less coercion on staff to make additional diagnoses, with smaller
organizations making more use of this kind of pressure. One informant working as a
23
psychiatrist at a larger organization said, “[If a diagnostic quota is not met] the staff will
be blamed and they will try to increase the target.” This informant went on to say that they
had not witnessed severe repercussions for psychiatrists at their organization who
consistently underperformed their quota. However, they stated that “in other organizations
yes, [you might be fired].”
5.2—Financializing trauma
Some providers discussed how donors (typically private foundations) demanded specific
confidential information about clients for use in research and to use for fundraising
campaigns:
Some private donors want to know the patient’s trauma story and want their
confidential information for their own data. And my manager told me, yes you
should send them all the data.
This provider went on to describe how this practice felt exploitative; that the clients were
not being consented to having their information used in these ways and that it was being
done without their knowledge. For this provider, this practice brought up issues
surrounding trauma voyeurism. For the clinics though, providing more diagnoses and the
trauma stories that donors requested helped to ensure future funding.
5.3—Resisting financialization pressures
Despite these pressures, the providers whom I interviewed felt that they had their own ways
of resisting these financial pressures:
It [this pressure to diagnose] is unethical… but for me—alhamdulilah—I didn’t
open a file for a client who wasn’t really suffering, who really couldn’t benefit. If
he is free of any psychological problem, I will write he is free.
24
And yet, it is unclear how this informant has chosen to problematize the issue of “benefit.”
In other words, how and where is the threshold of benefit versus harm for the patient set?
And, is that value strictly being located within the patient, or in consideration of the
patient’s larger social context? For this informant, it was enough if the client would gain
some relief of psychosocial suffering from engaging with the clinic. Many individuals who
have any degree of psychosocial suffering might benefit from being seen by mental health
providers, but in whom assigning diagnoses would be unethical.
Domain 6: Problematizing cross-cultural diagnostication
6.1—Validity of “Western” diagnostic criteria
The majority of informants discussed concerns about the validity of using diagnostic
criteria developed in the stream of European and American traditions of philosophy of
mind and psychiatry, i.e., “Western psychiatry.”
I also have doubts about these diagnosis because they often don’t have the full tools
to make these diagnosis… They are using Western tools that have not been
validated in Jordan, or for Syrians living in Jordan, or account for educational
differences.
Despite the gap in validated tools for diagnosing certain conditions, in regard to trauma
and PTSD, the majority of informants from Jordan and Syria felt that the model of PTSD
as understood in the Western psychiatric tradition was very translatable to how trauma is
conceived and experienced by their clients:
I think it is similar in our culture. When you ask anyone, “What do you think about
the trauma,” they wouldn’t say it is psychological trauma, they say “It’s a shocking
incident.” They say, “We are shocked.” Any individual in our culture when you ask
about psychological trauma they will say, “I am shocked because something
unexpected happened to me and it impacts me deeply, especially from the person
who is very close to me or anything that is very close to me impacts on my life
[sic].”
