The challenge of change

A new book about psychological well-being in the Gulf states assesses the effect of rapid economic development on health and happiness and comes to interesting conclusions, writes Mitya Underwood

Customers enjoy the opening day at The Galleria in August, checking out the stores and shopping at the brand new luxury mall at Sowwah Square on Al Maryah Island in Abu Dhabi.    Silvia Razgova / The National
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In his memoir, From Rags to Riches, about the early development of Abu Dhabi, Mohammed Al Fahim describes a place and its citizens a world away from the prosperous nation it is today.
"With the exception of a few prominent merchants and the ruling family who had homes made of earth or clay, the majority lived in barasti houses fashioned from the large leafy branches of the date palm trees. Of course there were no amenities such as [running] water or electricity. People used wood, brought in on the back of camels by the Bedouin, as fuel for their cooking fires."
There were no shopping malls filled with designer brands, or western university campuses teeming with students of all nationalities, or hospitals run by some of the world's most prestigious private firms. Crucially, there were also only a very few of the millions of expatriates who now inhabit the country.
As parts of the UAE and Gulf region have changed beyond recognition in a relatively short space of time, some argue it has become almost impossible for this generation to comprehend how their grandparents lived.
How and why this disconnect might have a negative effect on mental health is one of the topics explored in a new book by Justin Thomas, an assistant professor teaching psychology and psychotherapy at the Zayed University campus in Abu Dhabi, who believes that the extraordinary rate of social, technological and economic change has had a significant and unique effect on the people living in the region. "The arrival of oil wealth, combined with the rise of globalisation, has undoubtedly ushered in great material benefits, along with fairly radical changes to the lifestyles of the Gulf's citizens," Thomas writes in Psychological Well-being in the Gulf States, the New Arabia Felix.
"While this prosperity and socioeconomic progress is widely celebrated, it is also frequently lamented, sometimes viewed as presenting a challenge to the region's traditional Islamic and Arab cultural values."
The complexity of blending traditional values with modernity can create problems, Thomas says, for Emiratis who attempt to "slip in and out of character". Their public persona, be it in the workplace or in a western university branch campus, can be very different to the values and behaviours they are expected to adopt while at home with their family.
It can especially affect local young people who are trying to navigate their way through an impressively modern world while maintaining their relatively conservative and traditional values.
This constant struggle between sticking to traditions and preserving national identity, while at the same time creating much more global environments with the huge numbers of expatriate workers and modern influences, has created a unique environment in which certain groups struggle to adjust.
"Sometimes it's so easy when we have such a rapid shift that we don't even have the time to process these changes and integrate them, and to work out what this means for our lives," says Carey Kirk, a counselling psychologist at the LightHouse Arabia in Dubai, a centre that has patients fly in from across the Gulf region.
"We just go ahead and do things without thinking first: 'Is this in line with my values?'."
Similar economic development has been witnessed in countries the world over but at a much slower pace, giving everyone a better chance to understand and adjust.
"There is a huge generational tug of war happening," Kirk says. "We see it a lot with third-culture kids. This is pretty much happening [here] without Emiratis having to move elsewhere. It's a huge, rapid cultural shift within their home country. It's such a shift in every dimension of their lives."
The term third-culture kid, first used in the 1950s, refers to children who grow up in a different culture to their parents. That is, children who were born and raised outside of their parents' home country. Mixing the two cultures together creates a new, third culture. It is usually associated with expatriate children who have little connection with their homeland beyond a passport.
Existing and substantial research shows that these children are able to get along with people of any culture, but sometimes face something of an identity crisis themselves.
"[In the UAE] children are growing up with completely different ideals and completely different exposure to things; economically, culturally, socially and even technologically," Kirk adds.
"There are so many western influences, especially in Dubai, and there is opportunity for more people to be educated. In international schools, they come back [home] with very different perspectives."
The solution, she says, is to better explore how the culture in the UAE and similar countries has changed, and to look at the areas that might cause problems, especially for the younger generations.
It is also essential that there are good support systems in place.
Health care, and especially mental health care, is still in its infancy in the Emirates. There are few trained Emirati psychiatrists and psychologists, which is something Thomas is also trying to address.
Noof Al Qarni, a psychology student at Zayed University, is one of his pupils. As well as being an Emirati with a passion for psychology she has first-hand experience of struggling to balance her traditional values with the modern world in which she is immersed.
The result of the rapid changes, she says, is that today's young generation is struggling to adapt and find its new identity.
"What I see here is people are confused. Why? Because we want to be modern and we want to be up-to-date like the rest of the world, but at the same time we want to stick to our culture and we don't want others to think we aren't sticking to our culture.
"The culture is quite conservative, and it prefers us to be quiet and nice and not extroverted. But the modern lifestyle tells us to be extroverted and say what we think, and be 'who you are'. This is very different to what our culture tells us."
In his book, Thomas also discusses the effect of a rising divorce rate – something that is also often blamed on an increasingly modern culture. Statistics from Dubai show a 26 per cent increase in divorces from 2011 to 2012, according to the Dubai Statistics Centre.
In turn, some research suggests that significant levels of divorce are considered a contributory factor to the relatively high rates of depression.
A 2008 study from the UAE reported significantly higher rates of depression among single, widowed and divorced women compared to married women. There is also the question of how divorce affects children, especially when there are few support systems in place and there is a significant stigma attached.
Al Qarni, herself the daughter of divorced parents, feels that the community's reaction to divorce undoubtedly has an effect on the psychological well-being of those involved, especially the children.
"My parents divorced 17 years ago but I lied about it. I was ashamed of it. I would tell people my parents were together. I was worried about being judged.
"When I grew up and saw my mother working and doing so much for us, I thought: 'Why am I ashamed about it?' If anyone asks now I tell them the truth, I have nothing to be ashamed of. But when I was a kid I felt like I shouldn't tell people."
The body of research into mental health issues in the UAE and the region is by no means extensive.
The majority of the studies have been done by university faculty and students and usually rely on small sample sizes.
Student such as Al Qarni are integral to helping countries such as the UAE tackle some of the social problems that exist within the local community.
"I feel that I should use my experiences to help. When I was having a problem with anxiety, which is a problem here because of the expectations, I learnt how to help myself, and also being a psychology student helped a lot."
Al Qarni, from Dubai, thinks more should be done to help young people in the country, even before any problems manifest themselves.
Her ambition is to introduce what is known as social intelligence into schools to help young people navigate their way through life.
The idea is that it is social intelligence, ie a person's ability to effectively handle difficult social relationships and environments, rather than quantitate intelligence that defines a person.
By teaching young people social intelligence, it would better equip them to cope with the world.
"My dream job is to teach this in schools," says Al Qarni.
"When I was struggling myself, I read a lot of books on social intelligence and I realised it is very helpful here. I know a lot of people who have had anxiety because they have a lot of pressures and confusion.
"Things have changed a lot, but some parents are too busy to teach their children how to react, and to raise them well. Schools are a good place to do this."
Thomas's book, which is published on November 27, tackles four areas: anxiety, eating disorders, substance-related disorders and mood disorders (melancholy, mania and modernity). The culmination of more than a year's work, it collates most, if not all, the existing research on mental health. He presents the information clearly and concisely in a style that is accessible to the lay reader. As well as using findings from other researchers, he also draws on his own experiences from spending a lot of his teaching time with young Emirati women.
"Of course everybody feels sad and has different types of problems, and when you see it first-hand it brings it home," he says. "There are some really inherent cultural differences that I see."
None of the mental health issues are unique to the region, unlike some of the contributory factors. Within each of the four sections, there are a number of references to the limited help available to both mitigate and treat the problems.
The Briton hopes his work kick-starts a discussion about the best ways to deal with mental health problems. It will be the first time, he says, that all the relevant research has been collated in one place, offering a somewhat sober forecast unless the issue is addressed properly.
"One of the primary drivers behind me wanting to see this book come into existence was largely the idea that as someone new to the UAE it's always nice if there's a definitive or at least starting place where you can get an overview in research that has been done in your field, and that didn't exist for me," he says.
As well as being a document of record, Thomas hopes it will be used as a solid foundation for improving, tailoring and increasing the mental health provisions across the country.
The concept of transplanting western approaches to mental health onto Gulf countries is completely flawed, he says.
"The current world view is that psychological problems like depression and anxiety are illnesses so we have biomedical model that has dominated our discourse. But this is unravelling at the moment.
"Lots of the so-called intervention has failed to deliver; very little progress has been made. There are more people with psychological problems now than there were in the past. There [are] no solutions or cures.
"Here, there's an opportunity to do something innovative yet at the same time allowing it to be wedded to cultural values and tradition.
"There should be a menu of interventions available and some of them should be grounded in cultural values of the indigenous population."
In June, the UAE Minister of Health ruled that faith-healing clinics would not be allowed inside government hospitals, after being confronted on the issue during a session of the country's Federal National Council (FNC).
Abdul Rahman Al Owais told the FNC that faith healing had no place in the work of the Ministry of Health and that all healthcare services should be based purely in science.
Some of the research on the topic, however, indicates that this might not be the most constructive attitude.
A 2010 study from Saudi Arabia revealed that 42 per cent of the 1,408 people sampled had visited a traditional healer at least once in their life, with 24 per cent having done so within the previous 12 months.
Sadness and depression were two of the common reasons for seeking help, according to the study that was published in the Journal of Alternative and Complementary Medicine.
The authors of the study called for better integration of traditional healers in the healthcare system and tight legislation.
In his book Thomas says it makes sense for these traditions to be worked into the context of mental health care.
"Such a 'working with' might involve the cultural modification and refinement of existing talk-based psychotherapeutic interventions, with a view to making them more acceptable and effective within the Arabian Gulf context." he writes.
The argument is essentially whether religion and its traditions should be incorporated into modern medicine in areas like the Gulf, where in western medicine religion has no role whatsoever.
Shamsa Al Muhairi, a 19-year-old psychology student at Zayed University, says it would be counterproductive to ignore how important religion is to one's identity here.
"I think we shouldn't just pick western problems and try to fix them here," she says. "Doctors shouldn't ignore religion; it is very important here. If someone has the background of our tradition and religion, when they talk, it becomes more meaningful. This would help everyone."
But even within the context of mental health, where much of the treatment is psychotherapeutic rather than psychotropic, alternative and traditional methods such as Quran recitation are usually considered to have no place.
"At the moment anything 'alternative' is used in a condescending way such as 'We'll give you a good medicine but we will let you speak with your witch doctor, too'," Thomas explains.
"In some instances, that is justified. With physical illnesses, that is justified.
"A World Health Organization study compared psychological outcomes in developed nations and non-developed nations. If you did that with cancer, survival rates in non-developed nations would of course be lower. But with psychological outcomes, the developed countries lose.
"One of the things is the UAE has an advantage and they can adapt models from outside."
Kirk, of the LightHouse Arabia, agrees.
"I agree that religion has to have a place in medicine here. I think that's very important for professionals that work in the field of psychology and mental health in general to be able to work within that context.
"Coming to a psychologist doesn't exclude you from going to talk to your imam or receive spiritual counselling.
"It's about understanding how to be open to working from a spiritual perspective as well as a scientific perspective."