In the Gulf Arab states, as in many parts of the world, the treatment of mental health issues and the appreciation of these challenges have faced substantial social barriers. There has been a generational shift in attitudes, however. Recent polling has shown Gulf youth more accepting, with 62% saying mental illness is a “normal thing.” Youth-led awareness campaigns alongside public health education from mental health professionals are shifting the landscape of mental health care in the Gulf.

Kuwait and Saudi Arabia have introduced mental health laws and policies in the last few years that redefine mental health by addressing the stigma that surrounds mental illness and enhancing its treatment. Qatar launched a comprehensive National Mental Health Strategy, covering most components recommended by the World Health Organization, while other Gulf countries have emphasized mental health as a national priority and are scaling up mental health services. These new arrangements are now being put to the test as the stress of the coronavirus pandemic takes a psychological toll.

Cultural and Financial Barriers to Mental Health Care

Mental health and the treatment of mental illness are highly influenced by sociocultural factors. The culture of stigmatization has been one of the main challenges for people seeking treatment. People in the Gulf used to cover their faces when going to a psychiatrist, while today some walk in freely and ask for a consultation, said Haifa al-Qahtani, a Saudi psychiatrist.

In Kuwait, there is a stigma associated with visiting the Psychological Medicine Hospital (recently rebranded as the Kuwait Center for Mental Health), an obstacle for many who seek mental health services. Consequently, “some people end up struggling on their own and do not seek professional help as disclosure of mental health issues is possibly considered shameful because of social stigma,” said Hamad alHatem, a Kuwaiti psychotherapist and Ph.D. student in mental health counseling at the University of Florida.

Cultural factors such as collectivism, gossip, and reputation are important factors behind the stigma associated with mental health. For example, there is a common belief in Kuwait that an individual is either “crazy” or “insane” to seek mental health services. Since shame reflects not only on an individual but their entire family, how they are perceived by society deeply influences their behavior.

In the United Arab Emirates, a study with a sample of 325 people was taken, of which only 40% reported that they would seek help for their children if they experienced mental health issues. In Saudi Arabia, 80% of Saudis with severe mental illness do not seek any support. Due to the association of shame and stigma, “being secretive in seeking treatment is of the utmost importance to Arabs.”

Moreover, there are prevailing views about the region portraying faith as a barrier to seeking mental health services. A study conducted in Qatar showed that it is common among people with mental disorders to believe their illness “is a punishment from God or possession by evil spirits.”

Mental health stigma and negative attitudes toward formally seeking help are strong within Muslim communities. However, they are more often “reflections of cultural practices and discourse than of faith teaching per se,” said Mounira al-Dousari, a Kuwaiti Ph.D. student in counseling and psychotherapy at the University of Edinburgh. “In fact, a close reading of sacred scripture can provide resources to combat stigma and promote help-seeking, both formal and informal,” added Mounira.

Stigma is not the only obstacle in seeking mental health support. Financial burdens are often overlooked in this discussion. “Given that public hospitals are stigmatized, some people, even those who are ‘well-off’ might face financial barriers to accessing private mental health services,” Mounira said. “People also choose private over public services due to the feeling that purchasing private therapy gives them power and control over professional providers to assure their personal situation is more protected.”

Mounira noted that paying $225 per week to access counseling was a huge commitment for the participants in her research. “Imagine having four sessions a month. Even if you’re wealthy, this is a lot of money,” said one of her subjects. Even though mental health care is free in public hospitals, people lack faith in them and often report negative experiences, including breach of confidentiality.

Kuwait’s Mental Health Reforms

In Kuwait, a prominent social movement took place before the passage of the mental health law. Social media figures, famous artists, and advocates launched a campaign called #موعيب (no shame) through the ASAP initiative to break the taboo on discussing mental health disorders and reject the stigma associated with these issues. The ASAP Initiative is a private campaign that promotes mental health awareness. The campaign is part of the corporate social responsibility of the ASAP Beauty company, co-founded by Sheikha Majda al-Sabah and inspired by her own battle with depression. Moreover, civil society organizations hosted events in schools, universities, and various public spaces to encourage people to break the stigma and share their mental health experiences.

The hashtag النفسية _ الصحة_ #قانون (mental health law) trended to advocate for a comprehensive mental health policy. Moreover, civil society and mental health professionals have worked collaboratively to push for legislation. Campaigns such as “Mind Me,” Human Line Organization, and Taqabal contributed significantly to drafting the legislation.

As a result, Kuwait’s first Mental Health Law, assuring the protection of the rights of mental health patients, was passed unanimously in the National Assembly. The law was a “source of pride for Kuwait before the international community,” said Dr. Nayef al-Harbi, the president of Kuwait’s Center for Mental Health. “The law guarantees the patient’s freedom to make decisions and choose the treatment before it is taken by doctors, in addition to the patient’s right to determine visitors and their right to communicate with lawyers and human rights committees.” Hence, the law has tackled an essential obstacle to mental health: the culture of stigmatization.

“Even though the law is certainly a crucial step in the right direction, I strongly believe it should have strictly regulated the practice of mental health to adhere to higher international standards, like limiting it to people with advanced degrees in mental health-related fields,” said Hamad alHatem. “This is necessary to provide competent and ethical mental health services.”

Mental Health Challenges During the Pandemic

The effectiveness of these mental health policies is being tested amid the outbreak of the coronavirus. The conditions of fear and isolation experienced during the pandemic have exacerbated underlying mental health challenges underlining the need to address them openly.

“The sudden onset of the crisis led to an increased level of anxiety-produced behaviors such as panic buying and hoarding,” said Mounira. “The infection of fear and anxiety increased faster among people than the spread of the pandemic itself.” Other mental health practitioners have also experienced a significant increase in the number of patients struggling with fear, anxiety, stress, and isolation.

Among the most vulnerable groups affected by the quarantine are children and low-income migrant workers. “Home quarantine might impact children’s social skills, and it may be challenging to get back to normalcy,” Mounira said. “Low-income migrants, who are living miserably in ghettos under a strict lockdown, were even more exposed to mental health concerns … This is evident in the high number of suicides among migrant workers.”

In Kuwait, private mental health clinics were forced to shut down amid strict restrictions or switch to telehealth and online sessions, leaving Kuwait’s Center for Mental Health the only available in-person resource. Fortunately, an online platform, Corona Care, was initiated by more than a hundred psychiatrists and specialists to provide mental health care to Kuwait’s residents and citizens during the crisis. “The Corona Care website got more than 64,000 hits within three months, which shows the urgency of mental health during the pandemic,” said Mounira. Moreover, a mental health questionnaire was posted on social media for people to determine whether they need to visit a psychiatrist during the coronavirus period.

Gulf countries have strengthened mental health facilities during the coronavirus to mitigate the impacts. Crisis hotlines were introduced to provide free mental health support and remind the public of the importance of individual psychological well-being. Other initiatives targeted health-care workers who are also exposed to mental health issues.

The Saudi Health Services program was launched to provide moral and psychological support to health-care workers due to the pressure they face during the pandemic.

The Challenges Ahead

 The Gulf Program for Mental Health has urged all Gulf countries to introduce comprehensive mental health policies and laws that adhere to international standards by 2020. Almost all Gulf Arab countries have made progress regarding their mental health policies. However, there is still more work needed in some countries as their reforms do not meet international standards in terms of developing services and scaling up the number of trained therapists. Additionally, it is critical to raise awareness about the urgency of mental health and reduce the stigma associated with it.