“Do not take someone’s silence as his pride, perhaps he is busy fighting with himself.” - Ali Ibn Abi Talib

 

Shadows remain such until a light is cast upon them; otherwise, darkness prevails. It is a paradigm of modern psychotherapeutic thought that socioculturally-mandated moratoria on the discussion of mental health serve only to reinforce the harmful stigmata of the psyche--self-preservingly introspective to the point of reclusivity, and therefore without want of care. These misconceptions lead to biases of alterity in the quotidian interaction with persons diagnosed with mental illness. As Janis H. Jenkins writes, this manifests as “‘otherizing’ in the social rendering of persons diagnosed with mental illness as nonhuman or less than fully human” [1].

 

Perhaps no more blatant presentation of this phenomenon exists in the modern world than in the case of the Middle East and North Africa (MENA). Fraught with socio-political and ethno-religious conflict, the geopolitical region is a hotbed of violence, instability, and other impetuses for the development of post-traumatic stress disorder (PTSD), anxiety disorders, depression, and a myriad of other mental illnesses.

 

To compound the issue the region is woefully ill-prepared, both in infrastructure and in understanding, to effectively care for individuals diagnosed with mental illnesses. Beyond the physical toll that decades of conflict have taken on health resources in the region, nearly eliminating avenues of treatment, sociocultural perceptions of mental illness leave individuals ostracized or neglected and untreated. A literature review conducted by Sewilam et al. found overwhelming negative attitudes toward persons with mental illnesses in MENA [2]. In a study exploring the particular stigmatization of mental illness in Egypt, Coker reports that 56.6% of respondents said they would not accept a psychotic person as a member of their family [3]. In the same study, participants indicated a belief that individuals are to be considered responsible or even to be blamed for their mental illness.  

 

Under these cultural circumstances, seeking help for mental illness is an understandably difficult ordeal. Due to negative societal perceptions around seeking psychiatric care, patients may pursue inadequate avenues of care simply to avoid stigmatization. Patients may ‘somatize’ their symptoms and seek traditional biomedical care; others employ faith healers in their quest to cleanse themselves of spiritual possession (zar) or the Evil Eye (’ayn al-Hasuud), which are commonly posited as externalized causes of mental illness [4]. Given the stigma of mental illness, it is no wonder patients seek supernatural exculpation for their conditions.

 

Interestingly, respondents in the Coker study stated a belief that the cure to mental illness lies in the social domain. They listed social factors as a cause of mental illness and suggested social support as a primary method of treatment, all the while asserting a religio-moral imperative to help persons with mental illnesses [5].  

 

Herein lies the paradox of mental illness in the Middle East. It is taboo and undiscussable; those with mental illness become social pariahs. Yet the same people who pass these judgments on individuals with mental illness assert that it is the duty of the ill to seek help from the very society that shuns them.

 

What can be said for the roots of this paradoxical and discomforted understanding of mental illness? Perhaps universally, a hallmark of mental disorders is a sense of unreconciled self, a disconnect between how one understands himself and how he feels he is perceived by the world outside. This frustration lends itself to a distancing between an individual and the society he perceives to inadequately understand him. From the inside, it is seen as a homeostatic retreat into a haven of non-judgment and self-understanding that is free from the unsolicited and intrusive examinations of the outside world; It is perceived from the outside as a selfish beast of holier-than-thou reclusiveness, a publicly disinterested introversion.

 

As Ziad Kronfol mentions in an interview on mental health in the Middle East, “Psychiatry, perhaps more than any other medical discipline, is very culturally dependent. Although diseases may be the same, the manifestations of any particular disorder vary with the culture in which it appears” [6]. In Middle Eastern culture, one that is so heavily predicated on sociability and interconnectedness, the introversion of mental illness is unacceptable. As Jenkins argues, those who suffer are therefore relegated to the uncanny Other, human in form but disturbingly different, even unidentifiably incomplete, in composition. This irrational discomfort with the Other, this ‘pscyhophobia’, leaves those with mental illness immobilized for fear of judgment in seeking care or in struggling to cope on their own.

 

A fundamental recalibration of how Middle Eastern society perceives mental illnesses is necessary to better care for the individuals who face them in the region. It is important to capitalize on the existing communitarian principles that promote it as a social obligation to support persons with mental illness; inherent in this social model, however, must be an attitude of non-judgment. It may even be helpful to encourage patients to continue to seek help from faith leaders, as the values of self-understanding and belonging associated with religion can be powerful catalysts for expression and interpersonal relationships that can promote the healing process. However, the causes of mental illness must not be exported to the supernatural in an attempt to avoid stigmatization; this only further inhibits an open and productive conversation surrounding mental illness.

 

It is also important that these measures be enacted in legislative spheres, where provisions can be granted that better provide access to care for persons with mental illnesses. One such avenue is through curricula in medical schools in the region, where mental health is given nothing more than a cursory overview [7]. Better educating medical professionals about mental illness within the appropriate cultural context is perhaps the most vital step in promoting awareness of the issue and adequately addressing the needs of those with mental illness.

 

Above all else, the lived experiences of persons with mental illness must be legitimized in order to eradicate  stigma. A culture of acceptance and support must be encouraged. This is where true healing begins, not with a superficial understanding of mental illness but with a recognition of persons with mental illness as persons entire. And although initiatives have been launched in the Middle East to combat the stigma of mental illness, there is much to accomplish in the way of promoting a culture of true understanding. In the words of the Persian poet Rumi, “Maybe you are searching among the branches for what only appears in the roots.”

 

It’s time to get to the roots.

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[1] Jenkins, J.H. (2015). Extraordinary Conditions: Culture and Experience in Mental Illness. University of California Press: Oakland.

 

[2] Sewilam, A.M., Watson, A.M.M., Kassem, A.M., et al. (2014). Roadmap to reduce the stigma of mental illness in the Middle East. International Journal of Social Psychiatry, 61(2): 111-120. http://dx.doi.org/10.1177/0020764014537234

 

[3] Coker, E.M. (2005). Selfhood and social distance: toward a cultural understanding of psychiatric stigma in Egypt. Social Science & Medicine, 61(5): 920-930. http://dx.doi.org/10.1016/j.socscimed.2005.01.009

 

[4] Alosaimi, F. D., Alshehri, Y., Alfraih, I., Alghamdi, A., Aldahash, S., Alkhuzayem, H., & Albeeeshi, H. (2014). The prevalence of psychiatric disorders among visitors to faith healers in Saudi Arabia. Pakistan Journal of Medical Sciences, 30(5), 1077–1082. http://doi.org/10.12669/pjms.305.5434

 

[5] Coker, 2005

 

[6] Yahia, M. (2012). Dealing with mental illness in the Middle East. Nature Middle East. July 24, 2012.  Accessed November 9, 2016. http://www.natureasia.com/en/nmiddleeast/article/10.1038/nmiddleeast.2012.103

 

[7] Yahia, 2012