Mental health not all in the mind

In the Arab world, reluctance to seek medical help can be attributed to the fear that self-disclosure could mean betrayal of oneself and one's family.

Hasna suffered from trichotillomania – she compulsively pulled out her hair – and had to battle through her affliction alone, but she has vowed to seek help if she relapses. Mona Al Marzooqi / The National
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It started when Hasna was 11. Whenever she had a difficult homework assignment, she began compulsively pulling her hair out. She found it comforting, even when a handful of hair was piled up on the floor beside her.

The habit did not really bother her until she noticed her first patchy bald spots at the age of 14.

“The white scalp didn’t bother me much at that time because I was able to conceal it from my family by pinning it up or finding a new parting,” she says.

Like many people suffering from Trichotillomania, the clinical name for a hair-pulling disorder, Hasna, an Emirati, who prefers to remain anonymous, tried to deny she had a problem, using different tactics to hide her hair loss.

She first thought her studies were the cause, but “sometimes, I would pull when I am happy, when I am eating and watching television”.

In her second year at the university her situation became complicated.

“I began pulling strand after strand from the front left part of my hair. The scalp was transparent that it could be seen even when I put on my headscarf,” Hasna says.

After keeping her secret for eight years, she decided to seek help, although not from the medical profession.

“I went to one of my siblings and shared my suffering,” she says. “My sister was very supportive but, unfortunately, she failed to fathom the seriousness of my problem.”

Like anywhere else, people in the UAE live with the challenge of mental health problems. Yet there is often a reluctance throughout the Arab world to seek medical help.

It can be attributed to a fear of self-disclosure that could mean betrayal of oneself, family and, in some cases, a declaration of weakness. The lack of information and the stigma associated with psychiatric disorders also play a major role in stopping sufferers from seeking help from professionals.

Over the years, Hasna thought of seeking expert help, but found it extremely difficult to explain this to her parents. They thought that only those suffering from insanity went to see psychiatrists, she says.

“Too often, people who struggle with mental-health problems suffer from self-stigma and public stigma,” says Dr Fatima Al Darmaki, an Emirati who provides psychological services for the American Centre for Psychiatry and Neurology in Abu Dhabi.

“Controlling oneself or dealing with the problem without any medical help is the self-stigma people have.”

This stigma can be terrifying to many people, says Dr Al Darmaki, who is also a visiting associate professor at Zayed University.

“In this region, people are scared. What if the psychiatrists or the psychologists reveal their clients’ disorder? What if their colleagues get to know so-and-so seeks medical help?

“Many people do not know that all information is kept secret.”

After four years, as the bald patches on her scalp grew bigger, Hasna’s solution was to wear a hat, even at home.

“At some point, I applied eyeliner on the bald spot to disguise the defect,” she says. “It was heartbreaking to see what I was doing to myself. I blamed myself even though I couldn’t control myself.”

The cause of Trichotillomania is not known. It is one of the least understood disorders from the point of view of both sufferers and practitioners.

Every day Hasna would promise herself to not pull her hair, only to find a few hours later that her hand was performing the same repetitive action spontaneously.

For her sister’s wedding six years ago, the thought of going to the beauty parlour was particularly distressing.

“I dreaded family weddings because it meant styling hair,” she says. “I was praying for a miracle to occur on our way to the parlour.

“Thank God, the parlour was empty that day and the lady who did my hair didn’t ask about my condition. I was in a state of euphoria when my hair was done and I got to attend my sister’s wedding confidently.”

Asking sufferers of Tricholtillomani to stop the hair pulling is pointless, says Hasna. Even she cannot explain her behaviour.

“I wish I knew the root cause of hair pulling,” she says.

Now 24, Hasna stopped pulling her hair a year ago and has made a vow to seek medical help if she relapses.

“I can’t expect to receive help from Allah if I don’t help myself,” she says. “Today, I am proud of myself. I ask Allah to keep me steadfast and hope I never go back to pulling.”

One major problem with understanding attitudes towards seeking help for mental disorders in the Arab culture is a lack of research.

A study by Dr Al Darmaki in 2003 focused on the problems and needs of college students.

It found they were “likely to encounter problems during their college years” for which professional help would be needed, but they “may or may not seek help”.

Contributing factors were their confidence in mental health professionals, tolerance to stigma, and not wanting to reveal their problems to others.

The study, Attitudes Towards Seeking Professional Help, involved 350 college students from the UAE University in Al Ain.

The report also showed that those in their final year and those in arts-related subjects, were less worried about the stigma and had more confidence in healthcare professionals.

The study also showed people in the UAE relied more on traditional sources of help, such as family and friends, or faith healers and the Quran. Cultural barriers may also be preventing some from seeking professional help despite the availability of modern health services.

But the culture, says Dr Al Darmaki, changes as new generations become better educated and have a clearer understanding of how the medical profession can help.

Many people still think that “only an insane person needs to go to a professional”, she says, and the best way to deal with the taboo against seeking professional help is by fighting misconceptions.

Schools and universities should improve education, she says, and people should be taught the importance of seeking treatment at an early stage.

Justin Thomas, an associate professor of psychology at Zayed University, says the beliefs about the causes of psychological complaints can range wildly from a disregard for religion or the influence of djinn to a person being genetically defective.

“Many people have lost a little faith in medicine and in science,” he says. “There are lots of scandals, such as psychiatrists receiving huge incentives for promoting drugs that are often little more effective than placebos.

“There are also controversies about over-diagnosis, and our record of ‘curing’ problems is not great. The business model of health care makes many people sceptical.”

Thomas calls for medical professionals to be more focused on prevention and promotion of psychological well-being.

While psychiatry still struggles with an image problem in the region, there are individual success stories.

The story of Shaima has been an inspirational one for her family and friends.

In her early childhood, the Emirati, 33, talked normally. Then, at age 9, she started stammering.

Stammering or stuttering is a speech disorder that makes the sufferer repeat or prolong words, syllables and phrases. The stammerer may also stop during speech and be unable to make any sound at all.

“When I developed a stammer, it wasn’t obvious,” Shaima says. “With the passage of time, it increased 15 per cent through stress and emotional baggage.”

As she grew older, she avoided phone calls, worried people would notice her speech problem.

“One day, a close relative asked me to call Etisalat to inquire about the internet,” she says. “ When I wouldn’t do it, they asked whether I had refused due to my stammer.”

After the remarks, in front of her family, Shaima’s stammering became much worse. “Most of the time, I worried about people’s judgment, It stressed me out. I displayed all of my worries in stammering,” she says.

At college her stammering attracted unwanted attention from other girls and she was left with no friends.

In 2002 Shaima, who did not want to use her real name, graduated from the College of Information Technology in Dubai and got her first job as an IT specialist. Her work was mostly answering phone calls.

She recalls feelings of guilt towards her clients because her disorder was wasting their time. Some people even laughed at her.

Still, the job had some positive results for her speaking. “The more I answered phone calls, the stronger I felt. Had I not faced such hardship, I would have become weak and fragile,” she says.

One day in 2009 a colleague directed her to a hypnotherapist who also stammered.

“When I was told that the practitioner also faced the same problem, it helped me to trust her,” she says. “I was euphoric to find someone who would understand my pain.”

In her first session, the hypnotherapist at the Illuminations Well-being Centre in Dubai explained her role and the power of the mind.

During the second session, the practitioner asked her to go back to her first childhood memory in which she was afraid to speak.

She recalled a morning when she was full of enthusiasm and started speaking in a loud voice. In that moment of joy, a family member became angry with her and told her to be quiet.

This was the day she realised that being herself and expressing her feelings could hurt her. “If I stammer, there is less need to talk and interact with others.”

Before therapy, she had never thought of the incident. Recalling it shocked her. “After sharing the story, I released all negative emotions.”

The next day, her stammer had already improved.“ I stammer only 15 per cent of the time today,” she laughs.

As a result, Shaima is now studying to become a professional hypnotherapist herself.