transcultural

psychiatry
December
2008
ARTICLE

Arab Culture and Mental Health Care

M. FAKHR EL-ISLAM
The Behman Hospital, Cairo
Abstract This selective review describes recent literature and the authors
experience with mental illness and mental health care, and the impact of
cultural transformation on mental health in some Arab Islamic cultures,
particularly in Egypt, Qatar and Kuwait. Traditional extended Arab families
provide a structure for their members that may sometimes prevent and or
compensate for the effects of parental loss and mental disability. The role
of traditional families in the care of members and in medical decisionmaking is discussed. The impact of cultural change on Arab culture is also
examined, as is the effect of intergenerational conflict in traditional families.
Key words Arab Culture group identity mental health care traditional
family

Introduction
This review analyzes the role played by Arab Islamic culture in shaping
mental illness and mental health care, and examines whether culture
change has had an impact on mental health. Anthropologists have defined
culture as a socially shared, trans-generationally communicated, system of
implicit values, beliefs and attitudes, and explicit behavioural codes of
practice (Kroeber & Kluckhohn, 1952). However, social theorists have also
noted that culture is not static; it is affected by educational, economic and
political factors, and is subject to transformations, such as modernization
or fundamentalist revivals. This paper examines the relationships
Vol 45(4): 671682 DOI: 10.1177/1363461508100788 www.sagepublications.com
Copyright 2008 McGill University

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Transcultural Psychiatry 45(4)

between Arab Islamic culture and mental health care including both the
conservation of psychological health and the diagnosis and treatment of
mental illness. As the older literature on this subject was reviewed in this
journal in 1982 (El-Islam, 1982a), the present article deals with more
recent work, published both in international and local journals as well as
the authors clinical experience. Literature for this review was chosen
through a selective review of studies examining mental health in Arab
Islamic societies that employed the concept of culture, as defined above.

Demographic Background
The majority of studies reviewed were carried out in the Arabian Gulf states
of Qatar and Kuwait; several were conducted in Egypt. The populations of
Arabian Gulf countries include large proportions of expatriate workers,
including Palestinian, Jordanian, Egyptian, Syrian, Lebanese, North African
and Sudanese Arabs. According to the Kuwaiti census, expatriates make up
66% of the total population (Ministry of Planning, 1986). The lifestyle of
expatriates usually reflects more modernized codes of conduct than those
of the native population, and may provide an attractive model for local
youth to follow. Expatriate Arabs are not immigrants in Arabian Gulf
countries, but are allowed to reside as long as they are sponsored by local
institutions or individuals; they are transit or guest workers. The majority
of non-professional Arab expatriates are men who left their wives and
children in their home countries. On the other hand, many Kuwaitis and
Qataris have families of six to eight children, with more in polygamous
marriages (El-Islam, Malasi, & Abu-Dagga, 1988).

Culture in the Prevention and Genesis of Mental Illness

Traditional family care may play a prophylactic role in childrens development by compensating for the possible deprivation of early maternal care
because of disease, death, separation or divorce. Adequate compensation
by a mother-figure from the extended family may reduce a childs
vulnerability to mental health problems which may be associated with
deprivation of parental care, such as depressive, dissocial, and substance
abuse disorders (United Nations Office for Drug Control & Crime Prevention, 2001a). In a United Nations study of drug abuse in Greater Cairo
(UNODCCP, 2001a) paternal loss was significantly overrepresented
among heroin-addicted inpatients when compared to maternal loss,
suggesting that the family system may be less able to compensate for the
deprivation of father figures than mother figures. Adoption of children
into a non-blood related family is not allowed by Islam; a childs family
name always remains that of the biological father.
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El-Islam: Arab Culture and Mental Health Care

Support of family members for one another, especially support for the
younger by the older, is a time-honoured Arabic tradition, which was reinforced by the adoption of Islam. However, the acquisition of oil wealth
induced rapid socioeconomic and cultural changes in many Arabian Gulf
countries. In clinical psychiatric practice, many young people presented
following acute conflict with members of older generations. This
prompted a study of the possible association between intergenerational
conflict in the community (including native and expatriate Arabs) and
psychiatric symptoms in members of generations brought up before and
after the oil boom in Qatar and Kuwait (El-Islam, Abu-Dagga, Malasi, &
Moussa, 1986). While no significant link was detected in community
samples, the association in clinical material may be due to the increased
presentation of patients for professional help from families who were less
supportive by virtue of the intergenerational conflict itself.
Arab culture has always valued procreation. A study of a Kuwaiti
community sample (El-Islam, Malasi, et al., 1988) revealed a significant
association between psychiatric symptoms and contraceptive use among
women who practiced contraception for economic reasons despite their
belief that it was not allowed by Islam. The Islamic clergy in the
community studied, had issued an edict prohibiting contraception,
although other Muslim clerics (for instance, in Egypt) have issued edicts
allowing for birth control.
The profound social changes experienced by Qatar and Kuwait in recent
decades have been reflected in the symptoms and etiology of common
psychiatric disorders. For example, in Qatar advances in the education of
women and their increasing performance of multiple roles in the
community have led to the virtual disappearance of a chronic recalcitrant
culture-related somatic syndrome that mainly affected unmarried and
infertile women and that was characterized by giddiness or feeling faint
(dora), attributed to the head, nausea (chabid), attributed to the liver,
heartache and palpitations (gulb) and general fatigue (taban), attributed
to the limbs (El-Islam, 2006a). On the other hand, an apparent increase in
rates of psychiatric disorder followed Kuwaits enforcement of basic school
education requirements and the introduction of highly skilled occupations. These new challenges and social roles have proved particularly
stressful to some less intellectually endowed individuals, who might have
gone unnoticed through nomadic life (El-Islam, 2006b).
Other studies have suggested cultural traits, which may be protective
during a period of rapid social change, particularly in the sphere of work.
For instance, Arab inpatients in Kuwait hospitalized for myocardial infarction did not exhibit an excess of type A personality characteristics
when compared to other inpatients (Emara, El-Islam, Abu-Dagga, &
Moussa, 1986). In fact, the achievement drive, which is responsible for the
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job involvement component of type A behaviour, does not figure prominently in the positive adjustment/adaptation component of mental health,
as defined by most Kuwaiti Arabs (El-Islam, 2006b).

Culture and Decision-Making on Mental Health Issues

In the community studies reviewed, the value of individual independence
is often balanced or outweighed by that of interdependence within the
family unit. While the structural extended family, in which several
generations reside in a single household, is no longer as common in these
communities as it was a few decades ago, a functional extended family
system has emerged in which frequent contacts and interdependence bind
together several nuclear families from the same clan. In either case, the
decision to seek professional medical help is often made by the family as
a collective (El-Islam, 1994a). It is very unusual for a patient in such
communities to present to a psychiatric (or general medical) practitioner
on his or her own. Accompanying family members (e.g. parents, siblings,
cousins, nieces) support patients by demonstrating interest in their wellbeing and help to carry out treatment programmes. Admission to a
hospital is commonly a decision made jointly by the therapist, the patient
and the accompanying family member(s).
For patients who would be involuntarily hospitalized in non-traditional
societies, admission in Qatar and Kuwait is arranged after securing the
approval of relatives. Collaboration on this issue with patients families has
obviated the need for elaborate bureaucratic mental health legislation to
secure formal admission and fulfill certification. Verbal agreement alone
has sufficed according to traditional principles of practice (El-Islam,
1994a). When families agree to hospitalize psychotic relatives, it is important to consider not only the rights of patients, but also those of the families
who are at the receiving end of patients embarrassing, aggressive, and
destructive behaviour. This is heightened by the fact that associative
stigma is highly common in both Qatar and Kuwait; in other words,
behaviour considered abnormal brings social shame not only upon the
patient but also upon his or her family (El-Islam, 1994a). A similar
phenomenon has also been reported in Nigeria, another predominantly
Muslim traditional society (Asuni, 1990). Moreover, in communities, such
as those in Qatar and Kuwait, where the family typically takes decisions
for its healthy members, it would be unreasonable to deprive it of these
culturally approved rights in relation to its sick members (Harding &
Curran, 1978). In these cases, the family ensures the treatment of members
who may be too sick to recognize their needs, and works in alliance with
the therapist to improve the patients condition. Among communities that
employ this legislation-free professional-family-patient liaison approach
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El-Islam: Arab Culture and Mental Health Care

(e.g. in Qatar and Kuwait), it is almost unheard of for the hospital or

family to be taken to court by patients for illegal detention or violation of
human rights, although most such patients are familiar both with such
concepts and the legal process (Asuni, 1990). Of course, it can be argued
that the absence of complaints does not mean that patients have nothing
to complain about.
The family role in fore- and after-care of patients has been recently
rediscovered in non-traditional Western communities after budget cuts in
the 1980s heavily curtailed the provision of public social services. This shift
reinforces the need for traditional Arab communities to maintain the
centrality of the family in patient management rather than adopt Western
models (El-Islam, 1994a). Traditional families help their sick members to
reintegrate by arranging suitable marriages, employment and leisure time
occupation. In effect, such families carry out a number of social services
provided by the welfare state in many non-traditional societies. Clinical
impressions based on everyday practice in Qatar and Kuwait confirm this
welfare function of the family. Elders arrange marriages for all their young
relatives, including schizoid and schizophrenic individuals whose
emotional lives would likely handicap them in love marriages (El-Islam
& Abu-Dagga, 1990).
These traditional cultures encourage the interdependence, rather than
the independence, of individual family members, who internalize a group
rather than an individual decision-making process. According to Western
criteria, many family members would, under these circumstances, be
described as overinvolved with their sick relatives (Vaughn & Leff, 1976).
When the concept of emotional overinvolvement, as a component of relatives negative expressed emotion, was examined among Indian families,
the cut-off point for pathological overinvolvement had to be appreciably
raised in order for traditional measures to make sense (Wig, Menon, &
Bedi, 1987). Although no systemic studies of overinvolvement have been
carried out in Arab countries, clinical experience suggests that Arab
families in Egypt and in the Arabian Gulf are more likely to resemble
Indian than European families in this respect. The great concern of these
Arab families over the health of ill relatives motivates their attempts to
anticipate and fulfill the desires that patients are seen as unwilling or
unable to express for themselves. By Western criteria such behavior can
easily by interpreted as overinvolvement.

The Doctor-Patient Relationship in the

Arab Cultural Context
Patients expectations of doctors are culturally shaped. Many Arab psychiatric patients in Egyptian and Arabian Gulf communities expect their
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Transcultural Psychiatry 45(4)

psychiatrists to remove their suffering, making it difficult to expect them

to do any homework for themselves, as is common in cognitive or behaviour therapy (El-Islam, 2005). Often family members must become
involved and act as co-therapists, ensuring that patients carry out these
assignments. Psychiatrists who are unfamiliar with Arab culture may interpret such behavior on the part of the patient as a failure to cooperate
indicating an unwillingness to help oneself. Moreover, patients expect
therapists to understand and measure their symptoms against their own
cultural background, rather than that of the psychiatrist (El-Islam, 1994a).
Instead of working with intercultural commonalities or common
denominators, expatriate therapists often accept cultural pluralism as a
given and thereby undercut the notion of a socially agreed-upon
normality as a goal of therapy. To take one example, secular methods of
psychotherapy, which do not incorporate patients cultural codes, are less
likely to succeed with traditionally oriented Arab patients. In the field of
child psychiatry, this issue is of paramount importance when working to
secure the cooperation of Arab parents who would like to instill and
maintain their traditional values in their children (El-Islam, 1994a).
Arab patients and their families transfer onto therapists culturally
shared attitudes, especially those related to age and gender. For instance,
when dealing with intergenerational conflict in Kuwait, members of both
generations would be surprised if a middle-aged therapist did not reject
younger peoples anti-traditionalist and modern ideas. Similarly, a good or
effective therapist in Egypt and Arabian Gulf countries is expected to be
authoritative rather than to offer choices to patients. Patients also expect
therapists to take their side, rather than remain neutral, in family conflicts
and in reports to public authorities (El-Islam, 2005).
Rather than being limited to the patient-doctor dyad, the Arab
therapeutic relationship is often triangular, with other family members
equally involved in the process (El-Islam, 2005). Family members act as
welfare officers or social workers for most Arab patients, paying patients
clinical expenses and helping them restore their physical, mental and social
wellbeing after illness. In the case of mental illness, a first-degree relative
usually meets with the therapist before the consultation to provide information and meets again afterward to receive information. This pattern is
most common for the initial assessment interview. Given their role in the
therapeutic relationship, tactful handling of family members is essential in
order to secure their cooperation in patients subsequent care and rehabilitation, without jeopardizing patients rights of confidentiality.
Finally, the prevalence of stigma by association and beliefs regarding
envy may make patients and relatives much less likely to disclose various
facts of family life to a therapist. Information about abuse, sexual
activities, mental illness, and unlawful acts in which family members are
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El-Islam: Arab Culture and Mental Health Care

involved is often withheld from therapists because of the potential for

social shame. Because of a widely held belief that being the object of
others envy, particularly those who are less successful or prosperous, can
make one lose ones precedence, patients may also not disclose familial
success or income (El-Islam, 2005).

Arab Traditional Cultures and the

Establishment of Diagnoses
Murphy (1967) spelled out the difference between culturally shared beliefs,
which may not have an objective basis in reality, and delusions, which are
false beliefs that are not supported by a patients culture. Hence an emic
approach that considers local cultural categories of experience rather than
an etic approach (using external, cross-national or transcultural norms) is
crucial for distinguishing symptoms from culturally validated beliefs
during the process of diagnosis. An illustrative example is provided by
the application of Schneiders first rank symptoms, which have been
recommended for use in the diagnosis of schizophrenia in the tenth issue
of the International Classification of Diseases [ICD-10] (World Health
Organization, 1992), to Kuwaiti patients. Failure to distinguish what is
culturally alien from what is culturally shared among Kuwaiti patients can
lead to errors in diagnosis and management. For example, many Kuwaitis
and expatriates in Kuwait believe that the devil is capable of tempting
human beings to think, feel, or act wrongfully. To Western-trained
professionals, such beliefs may be mistaken for first rank symptoms of
thought control, thought insertion or passivity delusions (Al-Ansari,
Emara, Mirza, & El-Islam, 1989).
Obsessive ruminations are routinely attributed by Muslims to satanic
temptations, an association that is encoded linguistically: the Arabic word
wisswas designates both the devil and disagreeable thoughts (El-Islam,
2006c). Likewise, the most common ruminations among Egyptian Arab
patients involved antireligious rather than contamination themes
(Okasha, Saad, Khalil, Seif-El-Dawla, & Yehia, 1994). Treatment of
obsessive ruminations by behaviour therapy in Arab patients is more
successful if it employs repeated exposure to memories rather than to
deliberately produced fantasies of these thoughts (El-Islam, 2006c).
According to Islamic culture it is blasphemous to give up hope for relief
of suffering because patient endurance is rewarded in the afterlife. There
is evidence that this belief may shape the symptomatology of affective
disorders. For instance, hopelessness was not a prominent symptom
experienced by depressed inpatients (both natives and expatriates)
surveyed in Kuwait (El-Islam, Moussa, Malasi, & Mirza, 1988). The
somatic experience of chest tightness or heartache is a common symptom
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Transcultural Psychiatry 45(4)

in which the heart and chest are described as unable to contain or bear
the distress involved. Culturally insensitive medical personnel may regard
such complaints as purely somatic and focus entirely on possible physical
diagnoses. Repeated negative investigations of this sort may give patients
the impression that doctors are looking for something which they
cannot find, paving the way for the development of hypochondriasis
(El-Islam, 2002).
Because most women in traditional Arab cultures do not have
responsibilities outside the home, agoraphobia does not stand out as the
most common phobic disorder in clinical practice (e.g. in Qatar), as it does
in many Western cultures (El-Islam, 1994b). It is also possible that medical
and mental health professionals in Arab countries are less likely to search
for, consider or recognize agoraphobia in women. Because men have more
outside commitments and social encounters, social phobia appears much
more common in Arab men than in women in these traditional communities. Dissociation and conversion disorders occur more frequently
among Arab women, who are conditioned to feel weak or subordinate in
relation to men (El-Islam, 2001a). Womens physical symptoms of conversion are more socially acceptable than direct verbal expression of emotional
distress and protest, in part because somatic symptoms are generally
considered serious and worthy of attention, while emotional ones are
regarded as signs of weakness of personality or of faith (El-Islam, 1990).
Moreover, somatic and emotional symptoms call for different kinds of
explanations and help-seeking behaviours (El-Islam, 1990): somatic
symptoms require the aid of physicians while emotional symptoms need
religious help. Socially embarrassing and unprovoked aggressive behaviours
are most likely to be attributed by traditional Arabs to the supernatural
influence of demons (jinn) and hence call for the help of traditional healers
who can exorcise such noxious agents (El-Islam & Abu Dagga, 1992).
In a follow up study of symptoms with religious content (e.g. delusions
and hallucinations of prophethood) in Arab Egyptian psychotic inpatients
over a period of 22 years (Atallah, El-Dosoky, Coker, Nabil, & El-Islam,
2001), symptoms waxed and waned in their salience and fundamentalist
religious content in tandem with the general state of religious affairs
in Egyptian society, a pattern which applied equally to Muslims and
Christians. Such delusions can be seen as pathological extrapolations of,
or projections of individual psychopathology onto, widely shared ideas. In
another study, such culturally-specific delusions were found to be just as
likely to occur among highly educated Kuwaiti Arabs as they were among
their illiterate compatriots (El-Islam & Malasi, 1985) suggesting that
cultural beliefs may be difficult to erase by secular educational institutions.
In a United Nations assessment of trends and patterns of drug abuse
in five Egyptian governorates, abuse was initiated by a gift of the drug in
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El-Islam: Arab Culture and Mental Health Care

about 60% of cases (United Nations Office for Drug Control & Crime
Prevention, 2001b). Drug abusers often argued that the gift would be
culturally impolite to reject, especially if it came from a senior or highstatus person. Attempts to abstain from drug abuse were most likely to be
motivated by the distress of a family member, which had been induced by
the abusers decline in health or general wellbeing. Alcohol abuse was
found to be equally common among Muslim and Christian Egyptian drug
abusers, although their views regarding religious prohibition suggest that
the Islamic ban on alcohol is treated as more formal and complete than
its counterpart among Christian Egyptians. In fact, alcohol abuse sometimes begins in adolescence as a rebellious anti-parental or anti-religious
act among Kuwaiti Arabs (Bilal & El-Islam, 1985).

The Traditional Arab Family as Caregiver

A comparison of extended and nuclear family systems in the long-term
care of Qatari patients with schizophrenia (El-Islam, 1982b), revealed the
superiority of the extended family. In extended family systems, patients
were more tolerated for minor abnormalities of behaviour (e.g. grimacing
or not responding to others) and more likely to be allowed temporary
protective withdrawals. Family members would also create individually
tailored programmes of social contact for patients, escorting them to visit
particularly welcoming relatives. Perhaps for this reason, profound social
withdrawal was much less common in patients from extended family
systems than it was in those living with nuclear families. Finally, the foreand after-care, as well as the treatment compliance of patients from
extended family systems, was less likely to be interrupted, thanks to the
emotional dedication and a division of labour among the many family
members involved in caretaking (El-Islam, 1982b).
In a follow up study of parasuicide cases in Kuwaiti patients, the attitude
of extended family members to male and female individuals who survived
a suicidal attempt (Sulaiman, Moussa, & El-Islam, 1989) was found to vary
from an aggressive ostracism of the individual for having disgraced the
family, to doting attempts at providing the patient with whatever may have
been previously lacking. A peculiar combination that provided the most
stability was encountered in traditional extended family systems, where a
senior male figure adopted the aggressive role and a senior female family
member adopted the permissive role (Sulaiman et al., 1989).
Like conservative patients in other societies, traditional Arab women in
some societies (e.g. in Qatar) have been culturally conditioned to reveal
little or no depth of emotions to strangers including mental health
professionals. When they do reveal their feelings, the material produced by
women patients may prove quite interesting (El-Islam, 2001b). For
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Transcultural Psychiatry 45(4)

instance, behind many womens overt acceptance of polygamy as a male

prerogative lies a profound disapproval of the institution, as well as a
strong resentment of womens generally subordinate social role. Some
female patients have argued that if the rationale for veiling is that revealing womens faces or bodies is sexually arousing to men, then men should
also veil as they are equally exciting to women (El-Islam, 2001b).

Relationships between Psychiatrists and Traditional

Healers in Arab Cultures
The relationship between professional psychiatrists and traditional healers
varies in different Arab communities from the extremes of full integration
to outright opposition and enmity, with variable degrees of cooperation
and intermediate positions in most traditional cultures. Family members
may also share the dilemma of divided loyalty between the therapeutic
instructions of professionals and those of traditional healers. Psychiatrists
and traditional healers usually deal with each others failures. Formal legal
governmental permission for or sanctions against traditional healers varies
from one country to another (El-Islam, 2006c).
Clinical experience suggests that the same problems apply to the
neocultural treatment methods, now grouped under the rubric of
complementary and alternative medicine in some cultures. Common
therapeutic factors in these forms of therapy involve a healthy, supportive
therapist-patient relationship. Discrepancies between traditional healers
and mental health practitioners, include the reinforcement of patients and
relatives projections on supernatural agents by traditional therapists in
contrast to the attempts of professional therapists to undo such projections. Also traditional healers tend to include in their healing rituals
healthy members of the patients family and social network, which may
reduce stigma and help avoid patients isolation (El-Islam, 2001a).

Conclusion
Arab cultural knowledge and practices influence the definition, aetiology,
clinical pattern, diagnosis, management and prevention of psychiatric
disorders. Recent research confirms the value of the traditional role of the
family and of group identity in Arab communities. Cultural changes
resulting from post-oil boom increases in affluence and education have led
to some changes in patterns of symptomatology and help-seeking but have
not been found to be associated with overall increases in psychopathology
(El-Islam et al., 1986). Further work is needed to examine the diversity
within Arab societies and the impact of ongoing social changes on mental
health and illness.
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El-Islam: Arab Culture and Mental Health Care

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Mohamed Fakhr El-Islam, MD, DPM, FRCP, FRCPsych, completed his
psychiatric training at the Institute of Psychiatry in London and obtained his
diploma in psychological medicine (DPM) in Edinburgh. Upon returning to Cairo,
he lectured at the Cairo University Medical School. In 1980, Dr. El-Islam established
the first academic department of psychiatry at the University Medical School in
Kuwait. He is now based in Egypt where he focuses on training young doctors in
clinical psychiatry. His most recent cultural research included a 22-year follow-up
of religious psychiatric symptoms and the transcultural use of Schneiderian First
Rank symptoms in diagnosis of schizophrenia. Address: The Behman Hospital, 32
El-Marsad Street, Helwan, Cairo 11421, Egypt [E-mail: info@behman.com]
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Downloaded from tps.sagepub.com at American University in Cairo on February 23, 2016