An alarm clock beeps on cue repetitively, proudly performing the task it has patiently waited hours to do – awaken Rania Raine from her sleep. It’s 7 am, it’s time to wake up, the beeps sound with conviction and persistence.
But Raine has already beaten the clock. She has been lying awake in bed for the last two hours, willing herself to go back to sleep, but her mind won’t let her.
This is not a one-off case of early morning insomnia, but a battle with mental health that the 43-year-old British-Egyptian art teacher has been living with since she was a teenager.
“Looking back, I don’t think I realised what I had, but I definitely know that there was something that was affecting me – I had a sense of unease, a lack of peace in my mind.”
In time she started getting anxiety attacks, which she could not put a name to; she had nightmares and experienced flashbacks to a childhood trauma. Art was her escape, which then also became her profession.
“I’d wake up in shock, almost like I’m drowning, with thoughts racing through my mind, creating fear or anxiety – leading to feelings of not wanting to be here.”
By her early thirties, Raine was dealing with the breakdown of her first marriage. No longer able to silence the uncertainty that controlled much of her life, she began to unravel. “My mind felt as though it belonged to someone else, and instead there sat these thoughts I had no control over and they were taking up space inside my head.”
The eldest of four siblings, she initially didn’t tell her family what she was going through and would find other ways to cope. “I felt reluctant to tell them. My father was living with dementia, and we were all so busy trying to understand what was happening to him that I didn’t want to burden anyone with my own health concerns.”
Her family turned out to be her greatest support when they eventually found out, but she says the wider Arab community did not know how to address it.
Culturally, having a mental health condition or even discussing it has long been hushed in many Arab households and Muslim communities. The shame that wrongly surrounds conditions like bipolar disorder or schizophrenia, stems from cultural assumptions of genetic weakness, or fears of limited marriage opportunities for other siblings within the family, Raine says.
“I didn’t want to tell people initially, as I didn’t want to be labelled and told that ‘there’s something wrong with you’, especially in the Arab community. They think you are ‘crazy’, ‘a nutter’. There is no acceptance in understanding that most of us will, and do, experience a mental health disorder at some stage in our lives.”
Mental health spectrum
Research published in 2013 suggests mental health disorders are universal and sit on a spectrum. At some point in our lives, many of us will be affected by one or several of them – including depression, anxiety, bipolar disorder, schizophrenia and psychosis.
The Diagnostic and Statistical Manual of Mental Disorders lists 20 disorders in total.
In 2019, reports claimed there was a rising mental health epidemic, with depression alone affecting 264 million people across the world.
This year’s coronavirus pandemic and associated lockdowns have put an added strain on peoples’ mental health globally, even those without a history of concerns. Bereavement, isolation, loss of income and fear can all trigger mental health conditions or exacerbate existing ones, the World Health Organization (WHO) said.
“Good mental health is absolutely fundamental to overall health and wellbeing,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the WHO. “COVID-19 has interrupted essential mental health services around the world just when they’re needed most. World leaders must move fast and decisively to invest more in life-saving mental health programmes – during the pandemic and beyond.”
— World Health Organization (WHO) (@WHO) May 14, 2020
Even before COVID-19 there had been “chronic underfunding of mental health”, the WHO said, with countries spending less than two percent of their national health budgets on it.
With the pandemic, people with existing mental health issues have been unable to access mental health services during the global lockdown, with some form of disruption to mental health services in 93 percent of countries, leading to a further spike in mental health conditions.
But this wasn’t the case for Raine. Now living in West London with her husband of five years, she says the slower pace of life during the UK’s first lockdown in March 2020 offered her some respite. Disengaging with societal obligations created a calm space for her – and she was still able to teach (though online) her much-loved art to children – something she credits for getting her through life.
“My work as an art teacher and the art itself, allows me to continue ‘being’.”
It’s also because she was lucky enough to have found the professional help she had been seeking in her late thirties (pre-pandemic) when a psychiatrist in London diagnosed her mental health disorder – reactive depression and anxiety.
Raine says she was offered Eye Movement Desensitisation and Reprocessing (EMDR) therapy and tapping treatment – along with a mixture of antidepressants and anxiety pills which she was still able to access during the lockdown, and which she takes daily. But ultimately she says it has been a combination of the visualisation techniques taught by her therapist, and her art, that have pulled her through.
“Accepting my condition, and by allowing my family and loved ones to also accept and discuss it, all led to support. And it’s this daily support I have today, along with daily medication and outlets to heal, like my art.”
Shame and stigma
Raine has taught at schools in both the Middle East and the UK, and says she has seen first-hand what having one’s mental health needs ignored can lead to – at worst it can have tragic consequences and at best, is detrimental to a child’s learning.
“One of my students in Egypt committed suicide, and that’s because she was dealing with a mental health disorder that she was unable to openly discuss due to the shame and stigma attached to it, because of culture.
“It’s the ‘shame’ families have, that their child isn’t perfect, that their lives are not perfect and what will people say, what will the neighbours say, society say – and then it all leads to marriage, how no one will marry the child who has a mental health condition, or worse still, ruin the chances of marriage of the other siblings.”
A specialist in mental health disorders, Dr Mounira Aldousari, backs this up, but she also adds: “Mental health depiction in the media is extremely negative, especially in the Arab world. It is always associated with madness or aggressiveness.”
Mental health literacy
This year’s Arab Youth Survey (4,000 young adults, from ages 18 to 24, were interviewed in 17 different Arab countries) reports the number of people living with mental health conditions has risen, with those interviewed saying there is a lack of access to quality mental healthcare in the region.
Participants have said governments need to invest more in education and awareness campaigns and make quality mental healthcare more affordable.
And it seems countries in the Middle East are paying heed by doubling down on efforts to address and support mental health conditions, particularly in breaking the stigma attached to it.
In October this year, Qatar launched a new mental health education programme in some of its schools as part of a pilot project, making it the first Gulf country to do so.
Coinciding with World Mental Health Day, Qatar Foundation announced the initiative, known as the Wellness Ambassadors programme. Its aim: to promote mental health support and break the stigma attached to mental health conditions at school level.
“In Qatar, depression and anxiety are the two most common mental health disorders and both start during early childhood and peak during 13-17 years of age,” says Dr Ahsan Nazeer, division chief of Child and Adolescent Psychiatry at Sidra Medicine and project lead for Wellness Ambassadors.
“It is vital that mental health literacy programmes are introduced to schools in every country. We know, if we educate and equip young minds with the knowledge of what good mental health looks like, they apply their learning in their communities and amongst their peers, creating better mental health outcomes for all.”
Ambassadors from three Qatar schools received training on anti-bullying, depression, anxiety, suicide and self-harm and how to break cultural misconceptions about mental health – leading to “significant change” in attitudes and behaviours towards mental health.
It’s a step in the right direction, says Raine. She hopes more initiatives across the Middle East will lead to better conversations and steps towards seeking professional help. “The more we talk, the more understanding there is and the better outcome for all.”
Part of the human experience
Talk therapy is a popular tool in dealing with mental health disorders and, according to Dr Mamoun Mobayed, another way to destigmatise mental health disorders.
Mobayed, a Syrian-Irish psychiatrist and director of the Treatment and Rehabilitation Department, Behavioral Healthcare Center in Qatar, also encourages mental health literacy, psychotropic medication and, importantly, to have personal contact with people living with a mental illness “to remove the barriers associated with mental health and know they are normal humans with a disorder in the mind”.
Mental health disorders are part of the human experience, he says.
“Everything is centred in the brain. Our thoughts, aspirations, fears, our cognitive process. Our brain is our headquarters and it too, like other parts of the body, needs care and support especially when it is affected by neurological disorders or psychological disorders.”
But he says although stigma is still an issue when it comes to health challenges, it is not unique to the Middle East nor to mental health.
“Any disease thought to be infectious or bizarre-looking, like leprosy, has always been stigmatised. Even with COVID-19, there have been cases where paramedics working with COVID-19 patients have been avoided due to the fear and stigma attached to the virus.”
Holistic health – mind, body and soul
A quick look back at history shows the Middle East once led the way in psychiatric healthcare through Bimaristans – a Persian word meaning home for the sick. This name was given especially to hospitals that specialised in psychiatric care, while treating their patients holistically – mind, body, and soul. There was no taboo attached to seeking help for matters of the mind.
Bimaristans opened in Baghdad and Fes in the 8th century, Cairo in the 9th century and Damascus and Aleppo soon after, all specialising in psychiatric medicine.
Mobayed, a former professor in the history of Islamic medicine at Belfast’s Queen’s University, says the holistic approach used in Bimaristans was introduced by 9th-century physician Ahmed ibn Sahl al-Balkhi (PDF), where physicians “paid attention to a patient’s hygiene, diet, and rest and even offered music therapy”.
Balkhi’s well-known manuscript Sustenance for Bodies and Souls (Masalih al-Abdan wa al-Anfus) was ahead of its time. Written in language a lay person could understand instead of only being accessible to members of the medical profession, it opened doors to understanding the symptoms and treatments of mental and psychological health.
Mobayed believes the demise of the Muslim states politically and economically led to a pause in the region’s advancements in medical knowledge and technology.
In recent years, though, there has been a shift in attitude, with significant steps taken to return to prioritising mental health, particularly in the Gulf. As part of the region’s Program for Mental Health, it aims to incorporate mental health services across all primary healthcare facilities.
This year, all the GCC member states launched mental health awareness campaigns making it a national health priority, and invested openly in trying to break the stigma attached.
Iran, Morocco and Turkey are just some of the other countries in the Muslim world that have taken steps to support those with mental health disorders, with the latter launching a WHO-backed phone line counselling service to support COVID-related anxiety.
The power of social media
Aldousari, who is a PhD researcher in counselling and psychotherapy based at Edinburgh University, is pleased by the “much-needed” campaigns, but says social media is also making the biggest impact in breaking down taboos. With more posts and more people sharing personal stories, others feel more confident to open up about their own experiences, and in doing so, it breaks down walls.
“They are doing fabulous jobs in raising awareness. In Kuwait, we’ve had the Taqabal campaign since 2014. But the involvement of mental health professionals in social media to raise awareness is making the most significant changes.”
With more educational posts, podcasts and interviews, as well as clients and well-known faces sharing their experiences, acceptance of mental health conditions is growing.
“Because it’s no longer speaking theoretically but instead people are seeing real raw examples of such cases.”
‘You’re supposed to embrace it’
Noor Abdella* lives in Ethiopia’s capital city, Addis Ababa, and says seeing more mental health awareness campaigns tackling disorders is a good step forward, but is not the support she is looking for.
Abdella, 38, works in international development and travelled frequently for meetings and field visits pre-COVID-19. She lives on her own and had a busy social life – but she says the pandemic has taken its toll on her mental health as this is the first time in many years that she has come face to face with issues she has long avoided. She hides her personal battles from everyone, including her family.
“One thing I’ve noticed about mental health recently, especially during COVID-19, is just how easily you can get anxious, fearful, and mentally distressed,” she says.
“The more I am faced with these mixed emotions, I feel the desperation. Connecting with God becomes difficult when numb and feeling like a failure.
“I personally struggled with that. It wasn’t me doubting, in any way, it was me feeling I’ve lost that connection, that I was unworthy of forgiveness and I couldn’t turn to a lot of people.”
According to the WHO, people who have contracted COVID-19 may also be affected by mental health complications including “delirium, agitation, stroke, insomnia, anxiety or depression”, although this isn’t the case for Abdella.
— Al Jazeera English (@AJEnglish) November 18, 2020
For her, having more time and space to herself because of the pandemic brought out issues she hadn’t dealt with because she had always been travelling, been occupied, “so my mind has been looking at everything except deeply into myself and I no longer know what I am looking at”.
Abdella says she tried to raise her health challenges with her family, but knew they, and others in her community, believed depression and anxiety were signs of weak faith.
“One person told me ‘all you have to do is pray’. It sounded so easy, but the idea of depression is not something Muslims welcome, it’s almost taboo. You’re not allowed to be depressed, you’re not allowed to go through difficult times, you’re supposed to embrace it and that’s what being Muslim means.
“To accept everything good that happens to you and be grateful and to accept everything bad that happens to you, but not to view it as bad, and that patience is something you need to embody.”
She says she increased her prayers, which helped, but having a mental health challenge “doesn’t mean you are weak, or that this journey makes you a bad Muslim, it means you need support. Just like any other medical conditions that you would seek treatment for, mental health is also of utmost importance.”
Abdella has spent much of the solitude of this year researching therapy options – many have said she would first need to be assessed by a psychiatrist, not a therapist, for her to get any insurance to cover it.
She says she is looking specifically for a Muslim counsellor “so I would be able to have conversations that wouldn’t then guide me by Western ideology, because my issues aren’t Western. Yes, the issues are universal, but my questions are deeper.”
There is now a body of psychiatrists and counsellors who are trying to marry religious beliefs with professional mental health treatments, believing this leads to faster recovery for patients.
Faith in counselling
Aldousari is part of this and says: “There is a huge overlap between faith and culture. A lot of people find it hard to differentiate what comes from faith and what comes from religion, it’s so enmeshed.
“The Quran or teachings of Islam are not against the practice of counselling or the treatment of mental health, but instead incorporating it with new treatments will give better and quicker recovery results. As many studies suggest, those with stronger faith in any religion see quicker results in therapy.”
She says the mental health field and counselling have been dominated by Western approaches and theories for years, and still continue to be, but there are now moves to call for the integration of spirituality and religions in therapy, including a division of Christian counselling at the American Psychological Association and more research into Buddhism and counselling, as well as other religions.
“Scholars are paying more attention to religion and counselling after years of separation. When it comes to Islam, Muslim scholars and those working in the mental health field are working harder than ever to establish well-structured Islamically integrated psychotherapy models for those working with Muslim clients.”
She says she hopes faith and counselling will be seen as a continuum rather than discrete entities in good mental healthcare.
Whatever method of mental healthcare works for an individual, one thing the 2020 pandemic has taught the world is that with the unequal impacts of COVID-19 possibly leading to a widening of pre-existing health inequalities, investing in good mental healthcare is no longer an option, but a necessity, allowing us all to work towards, and hope for, a better future.
*Name changed to protect the person’s identity