By Ahmad Saneh & Natali Farran
Significant progress has been made in the field of mental health in Lebanon, largely due to the commitment and hard work of the mental health providers and specialists in our country. While the scenario is far from optimal and many challenges are present, it remains fair to deduce that individuals suffering from mental health difficulties can safely seek treatment and receive proper help.
Like in all fields, there are those who are good at their job, and there are those who are not. Here, we will try to equip service users in Lebanon with the knowledge about how to differentiate between a good mental-health provider, and a not so good one. We will also explore briefly the current state of clinical psychology practice in Lebanon.
The Favourable Profile of a Mental Health Provider
There are several important factors that need to be considered when choosing a mental-health care provider. Most people agree that once the provider’s credentials and competence are established, the personal comfort of a service user with the provider determines whether or not one will work with them.
Here are nonetheless some essential elements that need to be looked at when choosing the services of a mental-health provider –specifically, those offered by clinical psychologists:
- Licensure: Clinical psychologists and educational psychologists in Lebanon should obtain a license prior to practicing independently. Ask your potential mental-health care provider whether they have a valid license to practice.
- Skill and knowledge: Mental-health care providers are expected to have gained substantial skill and knowledge in the field and can apply them confidently in the clinical setting. It is mostly agreed that practicing without a theoretical approach might result in advice without a scientific basis. Along a similar vein, skilled service providers understand timing and do not implement particular interventions before the service user is ready. As a service user, you have the right to ask your mental-health care provider about their degrees, training, and experience, as well as the evidence-based practices that are being followed.
- Specialty: while most licensed psychologists are trained in various clinical areas, sometimes you might need a specialist in a particular field. Ask your potential mental-health care provider whether he/she has received sufficient training in a particular area that is relevant to your clinical needs, presenting problems, and expectations, and whether or not they have gained further experience in that area.
- Confidentiality: Maintaining confidentiality is essential for achieving clinician-client trust. Unless there is sufficient reason to break confidentiality or if the client has provided permission to break that confidentiality, mental-health care providers should refrain from exposing service-user information to others (like talking about a patient in a waiting room).
- Rapport-Building: It often takes time for the service user to trust the mental-health care provider and to open up during sessions. It is preferred that service providers take the necessary time to build rapport with their clients to establish trust and avoid jumping in too quickly.
- Empathy: This quality is fundamental to good clinical psychology services. Service providers are expected to be able to develop an understanding of how their client feels and respect those feelings.
- Professionalism: Like most jobs, professionalism is essential. Several expectations of mental-health care providers are present such as being on time, responding to their clients calls, and not talking about themselves during the sessions. Having appropriate boundaries is also crucial.
- Non-judgmental: Avoid the services of mental-health care providers who are judgmental of their client’s identity, behaviors, thoughts, and feelings. For instance, avoid service users who might pass judgments through phrases like “you should not feel that way,” or “you are a woman and it is unacceptable to do this or that,” among other examples.
Most mental healthcare services in Lebanon are costly, and clients devote a substantial amount of time and energy into these services. Making sure that the service provider is licensed, trained well, experienced, ethical, and trustworthy before opting into the service is crucial for optimal outcomes.
Core Principles of the Code of Ethics
The code of ethics issued by the American Psychological Association (APA) is driven by five core principles that outline the expected behavior of practitioners. These guidelines are followed by a wide range of service providers in the mental health field. Knowing these principles might further equip service users with the knowledge to differentiate between a good mental-health provider, and a not so good one.
- Principle A, Beneficence and Non-maleficence: Psychologists are expected to strive to protect the welfare and the rights of their clients while also seeking to minimize factors that might cause them to inappropriately use their influence. Psychologists are also expected to take care of themselves such that they can provide the best possible care to their clients. This principle encourages psychologists to strive to eliminate biases, affiliations, and prejudices that might influence their work.
- Principle B, Fidelity and Responsibility: Psychologists should participate in activities that enhance the ethical compliance and conduct of their colleagues. This principle dictates that psychologists consult with other professionals and institutions to ensure they can meet the needs of their clients. It is also asked of psychologists to “contribute a portion of their professional time for little or no compensation or personal advantage.”
- Principle C, Integrity: Psychologists are forbidden from stealing, cheating, engaging in fraud or subterfuge, or intentionally misrepresenting facts. This principle does outline parameters for when deception can be used –the benefits of the deception must outweigh the costs (such as in research studies).
- Principle D, Justice: Psychologists are asked to examine their own blind spots or personal biases, understand the boundaries of their competence, and to undertake an honest examination of the limits of their expertise to avoid providing or condoning unjust practices. This principle also states that people have a right to access and benefit from advances that have been made in the field of psychology. It is important for psychologists to treat people equally.
- Principle E, Respect for People’s Rights and Dignity: Psychologists should respect the right to dignity, privacy, and confidentiality of those they work with professionally. They should also strive to minimize their own biases as well as be aware of issues related to diversity and the concerns of particular populations.
Current State of Clinical Psychology Practice in Lebanon
In a chapter written by Brigitte A. Khoury and Sarah Tabbarah in The Oxford Handbook of the History of Psychology: Global Perspectives (2012), the authors mention that psychology in Lebanon has come forward immensely but advancements are still needed in all its aspects. Here we highlight some of the setbacks found in the clinical psychology field in Lebanon.
The National Mental Health Programme (NMHP) was launched in May 2014 within the Ministry of Public Health with the support of the World Health Organization (WHO), UNICEF, and International Medical Corps (IMC). The programme aims at reforming mental health care in Lebanon and providing services beyond medical treatment at the community level, in line with Human Rights and the latest evidence for best practices.
In 2017, the Ministry of Public Health signed off on circular No. 113 that prevented psychological practice without licensing from the ministry. Several experiences, such as obtaining a master’s degree, engaging in a certain amount of training hours, and passing the colloquium exam, are required to receive a license.
Some have noted however, that the exam can be passed after taking an introductory course in psychology, which puts the colloquium’s rigor into question.
One important issue is the lack of framework setting institutions. This is believed to lead to low and non-existing monitoring of practitioners and create issues such as lack of evidence-based treatment performed on clients and charging non-studied fees for the sessions.
The consequences include, but are not limited to, draining the client’s resources through ineffective sessions, and may even put them in harm’s way. For instance, in July 2013, the Lebanese Psychiatric Society (LPS) released a statement saying that homosexuality is not a mental disorder and does not need to be treated. They furthermore condemned conversion therapy (i.e. which seeks to convert homosexuals to heterosexuals).
Malpractice in this area, however, is still present although significant progress has generally been made.
Along a similar vein, lack of accountability might further harm service-users and drain their resources.
For instance, it is not uncommon for practitioners in the mental health field in Lebanon to ask for full body check-ups in contexts where they are not needed to further benefit their working place.
The same exploitation can be found with freelancing practitioners who recommend certain medical personnel or lab work for these check-ups to provide more business to family and friends.
The Lebanese Syndicate of Psychotherapists and Psychoanalysts (SPP) is a non-profit organization formed in April 2008 in Beirut to provide accreditation, standards of practice, professional identity, and self-regulation for psychotherapy professionals.
It is the first and only syndicate in the field of psychotherapy and psychoanalysis in Lebanon that attempts to unite practitioners in the country. The syndicate establishes guidelines, promotes education and training, strengthens the professional identity of the members, and provides networking and resource development.
Several committees have been formed within the Syndicate (ex. the Ethics Committee, the Finance Committee) to ensure an effective, influential, and informed treatment of diverse matters of importance to the profession. While the initiative has a positive purpose, lack of accountability and service monitoring are still present.
Some also believe that mental-health care services are not adequately integrated in the Lebanese healthcare program, and private insurance companies do not cover the costs of these services. This puts an additional burden on the service user.
Effort has been directed to improve the clinical psychology field in Lebanon, but such efforts face many challenges. For instance, a plan was laid out in 1992 to establish the Lebanese Psychological Association (LPA).
The LPA has several goals, including identifying which degree would allow its holder to practice in the field, and working toward a law regulating the career. The LPA has likewise been active in working on establishing guidelines and regulations for the practice of psychology in Lebanon.
Our hope is that efforts remain present and become effective, despite all the challenges that are faced.
Lebanon is home to many leading practitioners in the field of psychology in the Middle East. Like all disciplines, there are some who do not perform their job well, and do not abide by standards of practice and the code of ethics.
This can be further exacerbated by lack of accountability and monitoring as mentioned earlier. In psychology student discussions in Lebanon, you would often hear them commenting negatively about practitioners who are judgmental to their clients thoughts, behaviors, and feelings –being towards addictions, lifestyle choices, sexual preferences, and in a rarity of cases that exists nonetheless dismissing or judging the source of trauma or anxiety as an overreaction.
Judgments of that sort not only cannot only make therapeutic sessions ineffective, but also shape or shatter a client’s view of therapy and cause them to either choose not to open up as much or stop attending sessions.
In such discussions as well, students touch upon the topic of empathy. Some older practitioners and a minority of new ones were described as cold and lacking empathy. Studies have shown that 30 percent of positive change due to clinical psychology sessions depends on the service provider’s “common factors,” such as empathy, while 15 percent depends on the modality of treatment chosen.
Equipping clients in mental-health care services with the knowledge that can help them in choosing a suitable service provider is essential.
Likewise, being aware of the current status of psychology related legislations, rules, and regulations, can further enhance how clients navigate through such services.
There are many practitioners in Lebanon who are good-intended and are trying their best to support individuals in need of psychological help. We hope that with time and continuous efforts, the rights of service users will be protected more effectively.
Ahmad Saneh is a psychology student at the Lebanese American University. He has published in a peer-reviewed scientific journal. His research interest is in contextualized behaviourism, reflexes and first impressions, and community empowerment through spreading knowledge. Ahmad is an experienced writer and an activist in social justice. He is a certified member of ‘Nahnu Haddak’, which is a Lebanese based NGO that focuses on mental health, and a certified member of KIP, which is a Lebanese based NGO that focuses on social justice
Natali Farran is a neuropsychologist who worked as a senior research assistant at the American University of Beirut primarily. She is currently a clinical doctoral candidate at King’s College London. She is a certified mental health ambassador and the recipient of the Rajaa Salam Scholarship Award, Salaam Rishani Doctoral Scholarship, as well as the Rosa Burden North Bristol NHS Trust Prize, and the Cheyne McCallum North Bristol NHS Trust Prize.