Mental Health Services in the United Arab Emirates: Challenges and Opportunities

Mohamed A. Sayed

Head, Department of Clinical Psychology, National Rehabilitation Center (NRC), Howard University, Abu Dhabi, UAE

*Corresponding Author:

E-mail: mohamed.sayed@nrc.ae

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Abstract

Although there is a good standing and rich traditions of healing practices of psychological nature in the Arab world that go back to the eighth century and continues throughout the thirteen century, ironically, there has been a steady decline both in the breadth of services provided and the quality of services offered despite the increased knowledge and understanding of psychological practices. “The waning of the “Goodness” and viability of psychological practices maybe attributable in part to socio-political and historical events following that period in which the influence of Arab cultures as a whole over others has made the contribution of “Scholars of Arab” descend and extraction less visible and gives way to a paradigm shift that was incredible in its longstanding effects and consequent ramifications. Even today, most patients and families who are inflicted with a psychological problem, tend to see the infliction as part of a “mindset” that attributes a condition to “evil eye” or demonic passion”.

Although there is a good standing and rich traditions of healing practices of psychological nature in the Arab world that go back to the eighth century and continues throughout the thirteen century, ironically, there has been a steady decline both in the breadth of services provided and the quality of services offered despite the increased knowledge and understanding of psychological practices. “The waning of the “Goodness” and viability of psychological practices maybe attributable in part to socio-political and historical events following that period in which the influence of Arab cultures as a whole over others has made the contribution of “Scholars of Arab” descend and extraction less visible and gives way to a paradigm shift that was incredible in its longstanding effects and consequent ramifications. Even today, most patients and families who are inflicted with a psychological problem, tend to see the infliction as part of a “mindset” that attributes a condition to “evil eye” or demonic passion”.

Paradoxically, psychological services and healing practices that are rooted in the traditional ways of healing have seen an increase in the nature of services provided and a steady reliance on traditional healing methods. It seems to many potential clients in the Arab world that psychology as a science has not grown enough deep roots to be regarded as a distinct discipline trustworthy of providing treatment options when compared to medicalized treatment that rely heavily on physiological interventions via injections or drugs (i.e., psychiatry). The reasons are to be found in the prevailing notion that, psychiatric treatment in general and psychotherapy in particular, as an instrument of change are viewed as “just talk” with all the implications emanating from such conceptualization.

In the area of drug addiction treatment, for example, reticence to accept substance abuse problem and the guilt and shame accompanying them among people of Arab descent, have given rise to notions of health and wellness that may contradict internationally data-driven, practice –driven outcomes, and gives rise to cultural barriers and defenses against substance abuse problems, and consequently treatment is seen as futile. The utilization of culture as a defense has been demonstrated previously by the author of this paper and his colleagues at the Menninger Clinic where a group of patients with different psychological disorders were administered the Thematic Apperception Test (TAT) and the Rorschach Inkblot. The mother tongue narrative has sufficiently demonstrated that individual who were raised in a culture of Arab tradition and ethos, tend to use the language and articulation of suffering to “hide” pathological conditions when prompted to tell their story in the acquired language compared to mother tongue. This defense collapse effortlessly when the mother tongue is used in testing situation (Katsavdakis, Sayed, Bram, & Brand-Bartlett, 2001).

Another limitation, in addition to the overarching cultural barrier described above, has to do with the position of women and the availability of services which is offered to them. Of particular vulnerability to the culturally sanctioned practices is the position of women in the mental health facilities. Women in the United Arab Emirates have enjoyed a great degree of visibility, freedom and openness in educational as well as occupational settings. However, there is paucity in women’ programs dealing with psychological issues as alluded to above. There are some efforts to compact such stance as will be described below especially the growing awareness and the realization that women programs are to be established catering to this special population. The National Rehabilitation Center (NRC) in Abu Dhabi, United Arab Emirates demonstrates such efforts.

Of the characteristics that are often cited as distinctive of Arab patients is their reliance on pharmacotherapy. The later may serve to help patients avoid the stigma attached to mental illness. Although it is difficult to generalize assumptions underlining psychological services to encompass all Arab cultures or individuals of Arabic extraction, there are a set of unique characteristics shared by many people of Arabic origin.

Psychological services in the United Arab Emirates (UAE) will be used to illustrate the points alluded to above. Suggestions and recommendations will be offered to enhance the competency of the mental health services delivery to incorporate new findings that are starting to come to the fore.

This section will address the following distinct yet interrelated issues:

1-Help seeking behavior

2-Conceptualization of mental illness

3-Communication style and the use of metaphors in expressing psychological discomfort

4-Current practices and applications

5-Barriers and challenges in the provisions of mental health services in UAE culture

Help Seeking Behavior

In the Arab culture, individuals may not seek proper professional help due to fear of self-disclosure as self-disclosure may signify to them a betrayal of the individual’s family and/or might be seen as an unequivocal declaration of weakness (Al-Darmaki, 2003; Sayed, 2002). In addition, lack of the awareness of the availability of mental health services and the stigma of seeking psychological help may impact the help seeking behavior of Arabs from all classes. The prevalence ironically is not among the poor, the disadvantaged, and disenchanted; but among the educated class who typically seeks help either privately, travel to a different country or wait till it’s too late for intervention to work effectively. Among such group stigma attached to mental illness is simply too much to bear. By avoiding seeing psychological help in the form of counseling, they make it difficult for the counselor to help by employing negative attitude or by invoking power differential. Because of the closely-netted family configuration, middle and upper class individuals avoid seeing counselors from their own country and opt to others who have little knowledge of the intricate underling mechanisms of their culture and consequently doing themselves a disservice.

In UAE, mental health services were established in the mid 1970s, these services were in the form of psychiatric services in some emirates (i.e., Abu Dhabi, Dubai). In the 1980s, psychological services were viewed as supportive services in the treatment of patients who were receiving psychiatric help at the hospitals (Al-Darmaki, 2004). The need for provision of psychological services in UAE society became prominent as a result of the rapid social and economic changes which have taken place within the last 30 years in addition to the external influences of other cultures. Such changes seem to impact the values, beliefs, and role expectations of individuals which may, in turn, effect the psychological health especially for those who may have not being able to adjust to these changes (Al-Darmaki, 2003; 2005). Despite the governmental effort to establish a competent mental health services in UAE, these effort seems to be hindered by the shortage of the availability of practitioners who are professionally and culturally competent. In addition, the prevailing medical treatment model of practice in UAE and the tendency of the public to seek help from religious healers seem to contribute to the underutilization of mental health services in UAE which, in turn, impinge on the importance of services delivery in the society. Public trust in the mental health services and providers seem to be effected by the observed increase in malpractice by those who are not professionally component. The absence of licensure board, standards of practice and professional association to regulate provision of services seem to contribute to malpractice and to the negative attitudes toward seeking professional psychological help. Future research needs to explore these issues

However, a recent study on college students from UAE University revealed that students with more education and in art-related majors reported more tolerance to stigma and more confidence in psychological help providers (Al-Darmaki, 2003).

Conceptualization of Mental Illness

In the Arab culture, mental illness is viewed within the medical model. Patients suffering from mental health problems are usually treated with pharmacotherapy. Psychotherapy and counseling are considered “just talk” and, thus, are not curative. Talking to a therapist/counselor is not viewed a valuable method to bring about the desired change. Seeking the expertise of a psychotherapist is seen as weakness or a shameful event that might bring disgrace to the family (El-Islam, 1998; Okasha, 2000; Sayed, 2003).

A widely and an acceptable method of treatment of sickness in UAE society is traditional healing which is provided by a religious individual called “Mattawa” who often employs nonmedical, nonpsychological methods of treatment such as using readings from the Qur’an and traditional medicine. This method of treatment was the only known method of treatment of mental health illness in UAE prior the formation of the seven emirates in 1971 (Al-Darmaki, 2004). This type of treatment involves the belief that this treatment will drive the “evil spirit” and evil eye” away and cure the ill. This belief comes from the Arabic conceptualization of mental illness as having a jinni (devil) take over and change one’s life (Sayed, Collins, & Takahashi, 1998). Although modern medical practices are widely accepted, it is observed that the many people in UAE would consider this traditional method of healing over the medical or psychological treatment because of its acceptability in the society and the prevailing belief of the evil possession of the ill. Embracing of both traditional healing methods and modern medical practices is termed “cognitive tolerance” by Younis (n.d). The coexistence of contradictory values within the same culture or individual may account for the attitudes toward seeking psychological help of many individuals in UAE from both mental health providers and traditional healers with little discomfort.

Mental illness is also considered as a sign of weakness in the individual’s faith. Therefore, a person should strengthen his her relationship with Allah through prayers and readings from the Qur’an to achieve psychological comfort and peace of mind. Therefore, psychological treatment would be considered as the last possibility of treatment or when severe psychopathology is evident. In many cases, individuals are referred to psychiatric care through the emergency room or a general physician.

The choice of treatment method is usually controlled by the family of the ill and the family assumes the role of the guardians to explain the symptoms and complaints to the health care providers. This issue may present some challenges to the treatment of mental illness.

The following section deals with recent trends that are employed by the National Rehabilitation Center (NRC) dealing with special population. Additionally there are serious efforts by the center about integrating mental health services in primary care settings. There is a pilot program in five primary care clinics to incorporate mental health screening in primary care, and there is training offered based on h World Health Organization (WHO) mental health GAP. The NRC also did train physicians as a pilot study on (SBIRT) (screening, brief intervention and referral) for drug abuse problems again as an effort to of integrating substance use screening in primary care to deal with stigma. These efforts have proven successful, but the “web of interrelationships” that characterizes drug addiction continues to be a challenge.

Substance abuse among women in the UAE is seriously understudied and treated. The paucity of information pertinent to the treatment of women may be attributed to lack of proper statistics understated by social stigma and some other complex interactive matrix that minimizes the service of this underrepresented population. However, recently and following the enactment of the National Rehabilitation Center’s law, the NRC took it upon itself to further expand the service for this population notwithstanding the lack of accurate statistics. This expansive mode of operation in solidified by the presence of political power and awareness of the seriousness of Substance misuse among Emirati that may undermine the social fabric of society and deters the social services undertaken by the Authority. Although pattern of Substance misuse is currently being studied, the picture in not quite clear as of how many women among the UAE population could benefit from such services. There is nonetheless clear indication that the number is on the rise and intervention must be initiated to tackle the problem before it is too late

Embarking on its vision and mission, and empowered by its new mandate, the NRC started providing services for this population that rest on the following:

Provides a highly structured and highly integrated, and comprehensive women’s service that in anchored in sound scientific findings

Provides interventions that are individually –tailored, culturally appropriate and in tandem with the cultural heritage of the UAE’ culture and its religion. A goal-oriented schedule is customized around each client's personal progress in recovery. Peer support and interaction are an integral part healing process.

The service will begin by providing treatment to women who are shown to have a clear diagnosis of Substance Abuse with co-occurring psychiatric illness

The crux of the program, while offering traditional, state of the art therapeutic environment, will focus on some social components that were thought to enhance the therapeutic outcome of such special population, mainly family re-integration, family cohesiveness and inter-familial conflict resolution.

The women program will provide patients an array of services that ensure continuity of care from initial symptoms management and stabilization, to family involvement and building individuals’ capacity for self-reliance, self-initiation and family integration. Women will develop tools to prevent relapse, establish realistic goals for the future, and acquire skills for coping with the stress of everyday life.

As alluded to earlier, the women’s program proposed treatment protocol falls along a continuum that ranges from minimal outpatient contacts (as determined by the Severity Continuum) to long-term residential treatment. The latter will include detoxification services, step-down streaming that would eventually lead to independent living arrangement.

The women’s program at the NRC similar to other programs provided will utilize the most sophisticated, evidence-based approaches to the treatment of Substance abuse by integrating Dialectical Behavioral Therapy (DBT), Mentalization Based Therapy (MBT), Cognitive Behavioral Therapy (CBT), and Psycho-education Programs. A core built in component of the program will be Family Therapy

The program will utilize the expertise of our trained counselors, clinicians and physicians who will engage our clients in making proper diagnostic assessments, carry individual psychotherapy, and run a multidisciplinary matrix of a well thought out group interventions based primarily on Motivational Interviewing and CBT models to ensure best therapeutic outcome. Our group therapies for drug and alcohol abusers use affiliation, support, and peer and counselor insight to help patients struggling to move from addiction to recovery. The NRC philosophy is that each woman should have a highly individualized and flexible treatment plan that combines mental health and substance abuse treatment. Each group is conducted by a well-trained and skilled group leader providing a fostering and supportive environment where each woman can foster healthy attachments, provide positive reinforcement and act at a forum for client self-expression

Of the characteristics that are often cited as distinctive of Arab patients is their reliance on pharmacotherapy. The later may serve to help patients avoid the stigma attached to mental illness. Although it is difficult to generalize assumptions underlining psychological services to encompass all Arab cultures or individuals of Arabic extraction, there are a set of unique characteristics shared by many people of Arabic origin.

Psychological services in the United Arab Emirates (UAE) will be used to illustrate the points alluded to above. Suggestions and recommendations will be offered to enhance the competency of the mental health services delivery to incorporate new findings that are starting to come to the fore.

Communication Style and the use of Metaphor in Expressing Psychological Discomfort

According to the medical model, patients would characteristically communicate their symptoms and complaints to physicians who would then diagnose the problem(s) and prescribe medication. Individuals who seek mental health services would expect the same process when visiting practitioners. Therefore, they may get frustrated or annoyed by the strategies used by psychotherapists especially if it requires revealing family secrets and self-disclosure. Therapists who treat Arab clients may need to spend more time explaining the therapy process to their clients and explore their role expectations in the process.

In addition, many clients would express their psychological symptoms in a form of physical complaints to avoid the stigma of been mentally ill. The connection between bodily symptoms and the use of somatization as a metaphor to convey psychological distress in the absence of demonstrable organic bases has been established in some Arabian Gulf countries. For example, El-Rufaie, Al-Sabosy, Bener, & Abuzied (1999) reported high prevalence of somatized mental disorder compared to psychologized mental disorders using the 12-item General Heath Questionnaire (GHQ-12). In communicating their suffering and pain, clients may use other type of metaphor such as “my heart is burning” to express sadness or “my blood is boiling” to communicate anger and frustration. The use of such metaphor may reflect the clients’ cultural conceptualization of mental processes rather than lack of the ability to express them.

The relationship between the client and the therapist may be influenced by factors such as the presence of a family member during the therapy sessions or the need for an interpreter or a translator during therapy to facilitate the communication between the client and the therapist. The presence of a family member or a translator in the therapy process adds complexity to the therapy process and can cause role confusion for the client (Sayed, 2003). These issues need to be explored and dealt with in therapy.

Clients expect physician and psychotherapists to have the power to cure them or solve their problems. They expect to be passive in the therapeutic relationship and conform to the therapists’ orders. Psychotherapists would be viewed as not good helpers if they fail to meet clients’ expectations. Helping Arab clients to be active participants in their own therapy and to express their feelings and concerns would be very difficult and challenging for many therapists. In general, UAE culture does not encourage its people to express their emotions or focus on the self. Individuals tend to focus on themselves in relation to others (i.e., the family) and, in therapy; they are more comfortable bringing up non-psychological issues (e.g., academic, career issues).

Current Practices and Applications

Most of mental health services are provided within the hospital setting. Some hospitals in UAE are specialized in providing comprehensive mental health services for both inpatients and outpatients. These are located in major cities such as Abu Dhabi, Dubai, and Ras AlKhamah. Other hospitals have outpatient clinics and units for hospitalization. These facilities are well-established and their services are professionally trusted because it is viewed within the medical model. Other mental health services are provided within the educational settings (e.g., counseling centers, school health facility, and community mental health services). The services provided by theses agencies would typically involved individual therapy, and group therapy and other psychological services. These agencies usually lack resources (e.g., well-trained practitioners). According to our experience and observation, the demands for mental health services are in the raise so is the awareness of the need for a competent mental health system in UAE. For example, the number of clients seen at the UAE University counseling center is increasing when compared with the number of clients who sought services 4 years ago when the center started providing its services to students. The clients seen at the UAE University counseling center have showed interest in receiving therapy and working with their therapist to achieve their treatment goals. Yet, there were some clients who have expressed concerns about confidentiality and interference of their parents in their treatment (i.e., refusing the referral of their children to psychiatric care).

Barriers and Challenges in the Provisions of Mental Health Services in UAE Culture

The followings are some of the barriers and challenges of the provisions of mental health services in UAE:

Limited availability of competent mental health community resources. Despite the increase awareness of the need for mental health services in UAE and the increase realization of the impact of mental problems on both the individual and society, there is a shortage in the availability of competent mental health resources in UAE (Al-Darmaki & Sayed, 2004).

The use of interpreters and translators in psychotherapy (see Sayed 2003 for more discussion) present a complexity in the therapy process. More accurate communication between the therapist and the clients would require understanding of linguistic and cultural variations embedded in the Arab patients’ conceptualization of mental illness and health.

The role of the family (Lee & Richardson, 1991; Soliman, 1991). The family in UAE culture plays a significant role in the life of its members. It is the expectations that each member of the family expresses loyalty to the family and protects its honor beyond what is expected from their counterparts in other cultures. The family is viewed as the main source of emotional, social, and financial support to its members. Males are given the role of heading the family and most significant decisions and affairs (e.g., marriage, education, career, choice of treatment) are typically undertaken by the fathers or the brothers.

The Perceived Role of Religion (Lee & Richardson, 1991; Nasser-McMillan & Hakim-Larson, 2003). Religion is not only relegated to the practice of faith in UAE and other Muslim cultures, it is a way of life as values stemming from religious prescription and their interpretations. In addition, Muslims believe that all events are controlled by Allah and that sickness and health come from Allah and from Allah only. In therapy, Muslim clients would not only deal with the psychological distress but also with the guilt feelings stemming from the belief they must have done something to deserve it (Sayed, Collins, & Takahashi, 1998).

Cultural impact on expression of emotions (Cook, 1990). The UAE culture in general does not encourage its individuals to express emotions either publicly or in front of others. Therapists need to encourage clients to express their emotions and how they impact their overall well-being.

Confusion in relation to role expectations and the client-therapist relationship (see Sayed, 2003 for more discussion).

Expressing psychological problems in a form of physical concerns in order to avoid the stigma of being mentally ill (Sayed, 2002; El-Rufaie, Abuzeid, Bener, & Al-Sabosy, 1999).

Stigma of Mental Illness (Al-Darmaki, 2004; 2003; Sayed, 2002) despite the increase in awareness of such need for mental health services in UAE society. Efforts to increase public awareness of mental issues and to reduce the stigma of mental health problems have been taken place through media campaigns that encompass the whole country.

Whether to seek or not seek psychological help is largely determined by parents and other male figures in the family (e.g., older brothers). Seeking professional help is viewed as a family affair and it is up to the family to encourage or discourage their children to receive counseling or other mental health assistance when needed.

Malpractice and the absence of standard of practice: The relative absence in the past of a governing board or an agency to regulate services provided in the community seemed to have great impact on the standard of services offered in addition to the observed malpractice. The latter has been addressed by the UAE government in the form of a regulatory body that oversees all Medical. Psychiatric and Psychological regulations. (Health Authority of Abu Dhabi) and Dubai Health Authority. Both, in addition to the ministry of health (MOH) have contributed positively to regulate the health system with a great deal of success.

In conclusion, despite the earlier contribution of Arab Physicians to all area of Medicine, recent trends in dealing with psychological phenomena has been challenged by deeply-rooted assumptions about mental health. Recent efforts and the realization and acceptance of highly stigmatized populace have proven successful when an integration occurs between all providers by early screening, early intervention and treatment modalities that are rooted in scientific endeavors and sensitive to cultural norms and ethos.

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