In Treatment: Therapy in the Middle East Needs a Non-Western Approach

There’s long been a mismatch between the mental health care tradition conceptualized in the West and the non-Western populations it aims to serve. It is time to bridge this gap

In Treatment: Therapy in the Middle East Needs a Non-Western Approach
Sigmund Freud’s famed couch where he analyzed his patients/Bob Carey/Los Angeles Times via Getty Images

Every time she teaches a senior class in “History and Systems of Psychology” at Haigazian University in Beirut, Dr. Rita Mufarrij Merhej includes a module on Arab psychology theories, a primer from ancient philosophers to contemporary academic adaptations of mainstream theories. To her disappointment, this section of the class receives skepticism from her students who are too often immersed in the Western models that are held as the gold standard.

“They don’t get the essence that psychology has existed in our Arab legacy,” Merhej told New Lines. She has faced difficulties not only convincing her students of the validity of Arab-centric research but also, most importantly, finding it in the first place. Despite progress in academia in recent years, when it comes to the Southwest Asia and North Africa region (SWANA), it is difficult to find the information required for advancing research, including local data, psychology textbooks, testing metrics, and even adequate interpretations of psychology and mental health treatment.

This is unfortunate because uncritically using mainstream psychotherapeutic approaches developed on Eurocentric populations only hinders other groups’ access to mental health treatment. Despite efforts to build indigenous models of treatment, academic research lags also because of a weak foundation. And while growing awareness of the importance of diversity and cultural competency in the United States has helped adjust the cultural lens, a nuanced understanding is still missing. Local efforts are needed to implement better practices and fine-tune psychological approaches, a fact not lost on many SWANA-based mental health providers.

“The mental health field [in the SWANA countries] has essentially been imported from the West, particularly American models,” said Dr. Mona Amer, an associate professor at the American University in Cairo. Throughout her work at AUC, she has found it difficult to rely on local research as a resource to obtain useful information because of its scarcity.

For example, post-traumatic stress disorder (PTSD) is largely defined through the experiences of veterans after they have left war zones, often — and ironically — in the SWANA region. Yet research addressing the needs of the civilians left behind in these war zones remains scarce. In an interview published last year with Quartz, the chair of the Mental Health Unit at the Palestinian Ministry of Health, Dr. Samah Jabr, highlighted that PTSD is a Western concept that is not helpful for Palestinians. Its treatment addresses fears and behaviors that occur after a traumatic event has passed, but for many Palestinians, the trauma is ongoing and the diagnosis and treatment need to be different.

A more rudimentary problem therapists may run into while diagnosing clients – as patients are often called these days – stems from traits as trivial as speech habits. For example, native Arabic speakers tend to use hyperbole out of habit and may choose the extreme options when taking self-reported, multiple choice diagnostic tests. As a result, they tend to score higher on psychological tests developed in the West, and their diagnoses might be exaggerated.

Misdiagnosis can also occur due to cultural norms, or the perception thereof, by a misguided therapist. A woman’s removal of the hijab during a session with a female therapist, a client not responding to questions while performing ablution, or even someone speaking a bit too fast are all behaviors Western therapists have misperceived as signs of mental health problems, according to Amer. She added that overcompensation for cultural sensitivity can also be harmful. She said she has seen therapists ignore serious problems like domestic violence because they assumed it was part of the culture.

These inherent biases beckon an urgent need for cultural competency, a gap that Merhej faces all too often. “You sit there, and you go to all these websites, all these databases, try to get something that looks like you, and you don’t find it,” she said.

It is often said that Western society is individualist and Arab societies are collectivist. While this statement does not necessarily apply to all communities within these societies, it is important for therapists to keep it in mind when they assess the values of their clients and their ideal of mental well-being.

“The idea of being self-reliant, self-sufficient, and independent is really the paragon of mental health [in the West],” said Dr. Hani Henry at AUC, whose research explores the central role of culture in psychology. He added that this idea of mental health might not be shared in collectivist societies, and the debate about which is correct is useless. “I think they’re both healthy in their own way,” he said.

The convention under Western psychology is to treat a client as solely responsible for their thoughts, emotions, and behaviors, detached from interference, influence, or impact from others. It emphasizes “individuation” as an ideal. By contrast, in collectivist societies the “Self” — while of course recognized as an individual entity — is usually treated in relationship to family members and the community.

When considering Western individualist values, a therapist will encourage clients to make decisions that are best for them alone, such as moving out of their parents’ home. For a client with collectivist values, such decisions must include family and community, or they risk becoming maladaptive.

Indeed, studies on collectivist Asian societies in North America suggest that the options for counselors range from simply asking the client about their family and their role in it to having the family participate directly in some aspects of the counseling process. Overlooking this aspect of culture may discourage a population from seeking mental health treatment when they need it most.

“When you have this huge cultural gap between the person who’s supposed to help you, it contributes to enlarging the stigma against mental illness,” said Merhej. This lack of trust is harmful to the client-therapist relationship and can impede the treatment process.

Other areas of cultural mismatch involve the client’s conceptualization of the problem and the therapist’s suggested interventions. Amer added that matching proposed interventions to client expectations is important for the success of therapy. “We need to ensure that the population agrees with our theories and buys into them,” she said. Otherwise, they will not implement the strategies offered by the therapist, especially if the course of action contradicts their lifestyles.

The exclusion of faith, cultural beliefs and superstitions, spirituality, and religion in many Western models is illustrative of the mismatch between clients and therapists. Ignoring this as a component of a person’s social fabric may lead to unsuccessful therapy. Amer gave the example of people who believe they are possessed by Djinn, or demons. The most helpful approach is to gain their trust without alienating them, no matter how outlandish their beliefs may seem. Faith can be a powerful tool to help a religious client apply scientific practices that can be framed in a familiar context that is easy for them to integrate into their daily routine. If these clients believe religious practices might help them, their therapist should be able to integrate that into their course of action without dropping the science behind the interventions.

A growing number of psychologists around the world have been validating and developing these approaches, but they are not widely used and sometimes are discredited, often because of orientalist perceptions. An article published in 2011 in the medical journal Counseling and Values recommends therapists familiarize themselves with researched and tested practices that include religious traditions, which can be a source of community support and strongly held values.

Adjusting approaches to client expectations cannot be replaced with matching the religious, racial, ethnic, or cultural backgrounds of clients and their therapists. This cannot be the go-to alternative to cultural competence. For one, a match is not always feasible, especially for diaspora members seeking treatment abroad. Furthermore, a “matching” model, though preferred by many people seeking therapy, is not sustainable and does not guarantee that the therapist will adopt adequate approaches.

There is good news. The American Psychological Association has a division dedicated to diversifying research. The Society for the Psychological Study of Culture, Ethnicity, and Race is a major representative body for psychologists who conduct research on ethnic minority concerns. And over the past decade, research output has been increasing in the SWANA region. In the Arab world, between 2006 and 2012, there were 1,029 articles published (an average of 147 per year). This is about a 25% increase in yearly productivity compared to the preceding seven years, according to the latest review of publications on mental health.

But this growing body of research is still U.S.-centric no matter how local the research, if not for the simple fact that most of the publishers are based in the U.S., which may motivate researchers in the Arab world to shape their studies to appeal to these publications. “Sometimes this means focusing on parallels with the U.S. rather than particularities of their own,” says Dr. Yasmine Saleh, a Cairo-based psychologist and educator.

This might also explain why there are a multitude of studies that look at the prevalence of mental health problems in Arab populations and the obstacles faced in seeking treatment but not nearly enough research about the solutions.

“How do we know what kind of interventions can help? We don’t have the answers to that question yet,” said Amer. “We really need to do more research to find out what these populations want to see in counseling and in therapy, what they think could be more helpful for them, and what really does work.”

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