Mental Illness Stigma And Ethnocultural Beliefs In The Kingdom Of Saudi Arabia

Exploring the Nature of Mental Health Stigma in Saudi Arabia

The aim of the literature review is to offer the further understanding of the nature of the mental health stigma in Kingdom of Saudi Arabia. The literature review will try to explore the barriers, which people may experience during accessing the mental health services. This tries to discover the influence of cultural and religious beliefs on people. The literature review part help in understanding to the mental health illness. The experiences of people who are in search of mental health services are discussed. The treatment procedure of mental health illness is focused.  

In this paper, the critical realist concepts of mechanism theory and mental health illness are discussed. The main areas of the critical realism are discovered in relation to mental health and contrasted with positivism and constructivism. In view of Archer et al. (2013) the critical realism presents the alternative philosophical framework to explore the issues of mental health care.   

Key terms used for searching

The researcher has used various key words to search the articles and journals from the databases. The used key words are mental, illness, symptoms, treatment, prevalence, education, training, health care system, health services, behavior, problems, improvement, KSA, psychiatric and mental health education, metal ill people , perception, attitude, spirituality, mental health stigma, compulsive disorder, psychological problem, psychotherapy, epilepsy, cause of epilepsy, strategies, crisis, reduce mental health stigma and professional approaches.

To search the literature, articles and journals, the researcher has used various databases. The databases are the Google books, Google scholar, cinahl, pub med, Bielefeld Academic Search Engine, science.gov, Anthropology plus and NCBI. From these databases, the researcher has found various results, from, which he has taken few articles and journals. This was done based on the inclusion and exclusion criteria. However, the researcher has excluded various databases like cite based search and citeUlike, which did not provide any related articles.

The researcher selected the articles based on the inclusion and exclusion criteria. He has found approximately 210364 results from the different databases. From the huge result of articles and journals, the researcher selected only 36 articles that are and excluded others. He selected only those articles that are found in English. Moreover, he took the articles, which are not older than 15 years that is not older than 2002. He chose only full articles and is relevant to the topic. The researcher had chosen only those articles and journals that are authentic.

The researcher has excluded the articles, which were found in other languages and older than 15 years. He excluded the irrelevant articles and the incomplete articles. Many of the articles were not authentic that were excluded. The articles, which do not have sufficient information, are excluded.

Prevalence of mental illness among the Saudi arabia nation 

Critical Realist Concepts and Mental Health Illness

Al Atram (2015) stated that the population of the world is fast witnessing ageing and birth rates are falling. The older age is also susceptible to chronic diseases. This indicates the need of robust health and social support for the older age population. The researcher estimated the rate of psychiatric disorders among the elder population in Saudi Arabia. The Zulfi region was the study setting and a general health questionnaire was used. The results showed that psychiatric symptoms are not seen in 40% in the rural area and 15% of the elderly population in the urban people. Dysthymia was the most prevalent disorder amongst others. More research is needed with larger sample size to support these findings.

According to Sewilam et al. (2015) factors such as alcohol abuse and diminished immunity of somatic and mental structures have been considered as stigma in Saudi Arabia by the social and cultural societies of the human community. This stigma does not allow the individuals suffering from various illnesses to access optimal healthcare remedial treatment in terms of medication and non pharmacological interventions. Optimal awareness with legislative upholds is required among different age groups. Further, efficient clinical handover with optimal palliative care be undertaken by healthcare professionals of multidisciplinary teams.

Depression is considered to be one of the major factors leading to mental disorders and almost 13% of the population of Saudi Arab suffers from depression. This cross sectional study in the primary care setting in Riyadh, evaluated the prevalence of depression of the adults using assessment tools and questionnaires. The results indicated the 477 patients to be suffering from depression with the female population having significantly higher depression score specifically for the married ones. The lack of education and knowledge came out to be another influential factor in the study (Al-Qadhi et al. 2014).

Another study that focussed on the trans-global issue of depression, with emphasis on the alarming lack of knowledge in the developing countries (Alrahili et al. 2016). The purpose of the study was to analyse the attitude of the society towards the modern concept of depression and 137 individuals were studied in this experiment that lead to the results pointing the fingers to superstition for the backward perception with a few pertaining enough understanding to affirm that depression is in fact a medical illness (Alrahili et al. 2016). This study further validates how lack of knowledge can fuel backward thinking across population and with the right education the outlook of a society can change for the better

Prevalence and Treatment of Mental Health Illness

Yang et al. (2007) hypothesised that stigma has its own set of core effects on the society and mental illness. Two case examples were illustrated in the article- first-onset schizophrenia patients in the United States and mental illness in China. After a thorough literature review it was concluded that outlining different moral experiences would inform future measurements of stigma. It was proposed that new targets can be set for constructing intervention programs against the pressing issue by identifying in what ways stigma can be called a moral experience. Multiple perspectives and transactional methodologies can possibly capture the total scenario.

According to a research conducted by Sharour and Rehmani (2009) in the general ward of King Abdulaziz hospital in Saudi Arabia, patients with psychiatric illness are prone to discrimination. The quantitative analysis conducted with the help of a survey for the analysis of the prevailing conditions and it was found out that healthcare professionals of the target hospital were providing optimal palliative care and medication to the patients while they are prone to neglect and discrimination. Stigma does prevail in Saudi Arabia against the individuals suffering from mental illness.

Social stigma continues to be one of the major hurdles in the way of the mentally disabled finding healthy living and necessary help in their environment. Often the societal judgment worsens the situation instead of providing support and empathy to the unfortunates. This study aimed to define the different elements of social stigma, the attitude, the stereotypes and the prejudice and how that affects the mentally disabled (Ciftci, Jones and Corrigan 2013). This study focused on the discrimination faced by the muslim individuals suffering from mental illness and racial and religious context played the pivotal role in it. Along with identifying the different challenges it also offers a solution, adapting to which the society can improve itself to be free of stigma and discrimination.

Almutaiti (2015) mentioned that among the Saudi Arabia, the Saudi psychologist remains the information about the mental health illness. From the article, it is clear that most of the citizens are suffering from the mental health illness in Saudi Arabia. This can affect the thoughts of the individuals as well as the feelings, behavior and mood. If the signs and symptoms of the disease remains then the ability of the ill person becomes damaged. Mental health illness becomes the common thing in Saudi that needs to be diminished.  

Barriers Experienced When Accessing Mental Health Services

Abdullah and Brown (2011) mentioned in their article about the problems of the mental illness stigma in united State that can be expanded to a better account for the role of the culture. However, the article identified the relationship in between the mental illness stigma and the culture for different countries like African, Middle Eastern, European, Asian and Indian descents. The article showed that there are different cultural groups that may have influence of the mental health illness. The researcher selected both the qualitative and quantitative research for the study. However, the article has some research gaps, which can be filled with the more organizational information.

Obeid et al. (2012) aimed at examining whether misconceptions like possession by demons (Jinns) still existed among communities in Saudi Arabia in relation to being a causal factor for epilepsy. Undergraduate students and University educated school teachers were considered for the study. Most of the participants had witnessed epileptic seizures. 43% of the participants said that they believed epilepsy to be a psychiatric disorder. 40.3% of the teachers and 50.4% of the students considered possession to be a cause of epilepsy. It was concluded that Jinn possession is still a concept prevalent in the Saudi Arabia though many are well educated. Immediate public education is therefore necessary.

The research by Raza (2016) also focuses on the relevance of spirituality and religion when incorporated to the care system for the mentally ill. However, this study takes into account only the female Muslim population and how the religion and spiritual inclination affects their attitude to help seeking when facing psychological abnormality. This study evaluated the Islamic treatments and their benefits and consequences to the mental health. The results indicated at religion playing a pivotal role with notions like jinn possession, spiritual weakness to be the cause of medical psychological problems. The cultural background hinders the treatment of psychic diseases and studies like this can open the gateway to understand and eradicate such idiocy.

According to the research conducted by Halwani (2013) religion and spiritual upbringing plays an important role in determining the mental health of an individual further remedial psychotherapy. Quantitative analysis was undertaken with the help of optimal surveys determining that Islamic culture and religiousness affects the mental wellbeing of individuals in Saudi Arabia. Results determined that vast number of individuals preferred non pharmacological interventions such as psychotherapy besides medication.

The schizophrenic patients often are subjected to a number of societal and cultural influences on the adversities of their mental and physical health. As the cultural backgrounds heavily interferes with the life style and perception of the individuals of the society this study aimed to investigate the impact of this factors across three geographical regions. 148 patients were examined using different assessment scales like SAPS, SANS, MMDAS and questionnaires like ABQ and SPQn (ALNzawi 2012). The results highlighted the gender to be an influential factor with females having the majority, persecutory delusions as the common in occurrence and supernatural superstitions to be the main hindrance to treatment of such patients (ALNzawi 2012).

Influence of Cultural and Religious Beliefs on Mental Health

The purpose of this study was to evaluate the concept of faith healers and its association with the individuals suffering with psychiatric disorders. This cross sectional study examined 383 individuals that used the faith healing services and compared them to 424 selected individuals that do not use the services (Alosaimi et al. 2014). The neuropsychiatric survey yielded mixed results, with almost entireties of the faith healer service users to have had a past history of mental illness and were relied much more on the faith healing services with a good proportion of likelihood to visit again. The results indicate at the strong trust of the natives on the faith healing services and provide a good opportunity to study the psychosocial factors that facilitate their trust on faith healers (Alosaimi et al. 2014).

This study provides a different take to the effect of traditionalism and religious believes on the health condition of the patient. Previous studies suggest that the traditional and religious perception can often impart a positive effect on the patients’ condition and thus study speaks about the ethical reform that can be brought forwards by prioritizing the traditional, religious and spiritual context into patient improvement program incorporating guidelines and frameworks that aligns with the spirituality of the patient to deliver optimal care. This innovative concept can prove to be revolutionary in improving the conventional patient care techniques if utilized carefully (Nolan, Whetten and Koenig 2011).

In the article by Al-Solaim and Loewenthal (2011), the author chose 15 young women, who were suffering from obsessive-compulsive disorder in Saudi Arabia for the interview. He showed that religion does not play any role in the mental health illness. However, the religious symptoms are reported as the other symptoms that has important role. People who suffer from the OCD needs more care and seeks the help for the treatment. The professionals should be trustworthy and the trustworthiness criterion needs to be religious and specific. However, the authors showed that the ODC and religion has a link in the psychological literatures though both are completely different from each other.

Halawani (2014) stated in their article that international psychological applications conference and trends might have impact on the psychological illness treatment in Saudi Arabia. In last decades the religion and spirituality in the psychotherapy focuses on the understanding of the religion and spirituality. This can be related to the client and psychotherapist relationship. Therefore, the religion and spirituality may improved the relationship of the client and psychotherapist.

Discrimination Against Individuals with Mental Illness

Koenig et al. (2014) reviewed the past, present and future of mental health care in the kingdom of Saudi Arabia (KSA). The article highlighted that there is a wonderful progress in the treatment of mental health disorders in the past 60 years in KSA. The recognition of mental health disorder has been remarkable in the last two years speaking in a more precise manner. Immense opportunities lie for undertaking systematic research on the course and management of emotional and mental disorders in KSA. However, one needs to agree that religion, family and culture have a predominant impact on understanding mental disorders.

Almoshawah (2010) evaluated the issue of mental health services in Saudi Arabia. The study had the main focus on personal development, referrals and characteristics of psychiatrists in KSA. A questionnaire was used from January 2008 to April 2009. Moreover, 158 psychiatrists were considered as the sample population. Out of the total number of psychiatrists, 90% reported to have a strong awareness of mental health services in the country. However, they were not clear about the roles and responsibilities in relation to care services. They required more training to be expert in their field. Personal developments were also pivotal in this regard.

According to a research conducted by Ahmed (2016) it is essential to integrate mental healthcare awareness sessions into the pivot of defence of an individual. Such incorporation increases awareness regarding the illness at an early age and opens door for secondary remedial treatment. Furthermore, this enhances the need of treatment among vulnerable people and can be undertaken by screening process that conducts surveys for the determination of the extent of the need. This is done by formulation of multidisciplinary teams, optimal training, updated legislations, auditing and medical and non-medical assistance.

Alamri (2016) mentioned in their article that in Saudi Arabia, the mental health problems are prevalent and the population is at the high risk. As it is the common problem in Saudi Arabia therefore, the chance of availability and accessibility of mental health services in KSA. The only acceptability of mental health outcomes shows the depression and anxiety. The author in the article stated the administration of Arabic Hospital Anxiety and the Depression scale to the sample size. For the study, the author selected huge amount of sample size (237 patients). The needs of the people who are suffering from mental health illness are included in the study and were surveyed.

Prevalence of Mental Illness in Saudi Arabia

According to a report by World Health organisation, integration of optimal treatment of mental health into the primary care of patients is essential because of increase in mental disorder cases. This leads to various somatic maladies which may or may not be curable. Incorporation of optimal mental health treatment will lead to easy access of facilities by patients, protection of the fundamental and ethical rights of patients and will generate effective results. Furthermore, this incorporation will decrease the prevailing gaps such as uneasy access to facilities, expensive treatment and no awareness leading to treatment of lesser people (World Health Organization 2008).

This research study attempts to analyse the entire mental health system in the Saudi Arabia, to provide strategic steps that can help in improving the standards and quality of the care provided. The study has used the mental health assessment interments provided by the WHO, and the results indicated the community mental health services to be lagging behind when compared to international trends of the first world countries. It also indicates at the dwindling professional workforce skilled optimally in the field of mental health care in the Saudi society. These studies are crucial for the assessment of the inadequacies of the health care system and provide a clear insight about what changes are necessary and where they should be incorporated (Qureshi, Al-Habeeb and Koenig 2013).

Staiger et al. (2017) undertook a qualitative study to explore the facilitators and barriers of help-seeking among persons who are unemployed and have mental health issues. The rationale behind the study was that individuals who are unemployed and have mental health problems often are found not to use mental health services. The available therapies therefore are not beneficial. Fifteen qualitative semi-structured individual interviews were considered with the selected population. It was concluded that unemployed people having mental health issues face facilitators and barriers while seeking help in three areas; conditions and structures of healthcare, discrimination and stigma and mental health literacy.

Ahmedani (2011) opined in their article that mental health stigma mainly operates in the society that is internalized by particulars. The health professionals can attribute this. These ethical issues may act as the barrier to the particulars, who seek the treatment services. In such cases, the dimensions, epistemology and theory of the mental health stigma have implication on the social work profession. The people of Saudi people are in search of the mental health treatment that is discussed in the article. The article explains that stigma has different levels, theories and epistemology.   

Misconceptions Around Disorders Like Epilepsy

Sewilam et al. (2015) stated that stigma acts as a key barrier in the accession to care provision and treatment for individuals with mental health conditions. The researchers reviewed existing literature related to stigma shown towards mental illness in the Middle East for informing sustainable and effective interventions. The PubMed database was used for this purpose. It was found that stigma does not exist to a considerable level in the Middle East. Such kind of attitude is high towards mental illnesses such as alcohol abuse and low for psychosis and depression. For reducing stigma, education of the families would be the key strategy.

The experience of the Arab-American populations seeking psychological help is not much explored in previous research, hence this study aimed to investigate the attitude of this minority population towards the formal mental health help services. The study evaluated variable using the model of help seeking pathways for Arab muslims and the result showed the traditional believes and superstitions fuelled by lack of knowledge about mental illness to be the root cause of this issue (Aloud and Rathur 2009).

The experience of the Arab-American populations seeking psychological help is not much explored in previous research, hence this study aimed to investigate the perception of the Arab population towards the psychological help service providers and how that affects their negative attitude towards the helpers. The study evaluated variable using the model of help seeking pathways for Arab muslims and the result strongly pointed towards the traditional believes and superstitions fuelled by lack of knowledge about mental illness (Aloud 2004).

According to AL-ADAWI (2002), socio cultural factors and philosophy often dictate the mental illness. The main purpose of the article is to examine the social factors that can influence the attitude of a person towards the mentally ill people in a country like Oman. The researcher had selected medical students, Oman public and relatives of mentally ill people as the sample to conduct the research. However, in the study the researchers showed that there is no relationship in between the attitudes of the people with mentally illness and demographic variables like age, sex, educational level, personal exposure and marital status to the people with the mental illness.

Wilrycx et al. (2015) examined the impact recovery-oriented care-training program for mental healthcare professionals have on mental health consumer outcomes. The Mental Health Recovery Measure (MHRM) and the Recovery-Promoting Relationship Scale (RPRS) was used and 142 consumer having mental illness served as the sample population. Data analysis was done with the help of software packages. Scores showed a change over time for the subscale of ‘learning and new potentials’ and ‘self-empowerment’. It was concluded that after one year of completion of the recovery-oriented training program for professionals, effect is more profound for these two aspects.

Studies on Attitudes to Mental Illness and Seeking Help

In the article by Al- Habeeb (2003), the aim is to analyze the narrated symptoms and the treatments of the mental illness. Faith healers mainly help in analyzing the pattern of the symptoms and treatments in Saudi Arabia. For the study, the researcher selected 45 faith healers for the self-administration and questionnaire. It is seen from the result that most of the faith healers have poor psychiatric symptoms that could not differentiate specifically the spiritual disorders. The researcher showed in the result that religious concept is very helpful in the treatment of the mental illness and the clients show improvement by this method.

Koenig (2009) stated that spiritual and religious factors are constantly being examined in the field of psychiatric research. Religious practise and beliefs have been linked for many decades with neurosis, hysteria and psychotic delusions. Nevertheless, the research conducted recently has indicated the existence of another aspect of religion that serves as a social and psychological resource for leading with stress. The clinical implications of the findings of the article indicate that religious practices and beliefs contribute greatly to mental pathology. The limitations of the study were that the review conducted by the researchers was selective and not systematic and that the clinical applications were not addressed.

Koenig et al. (2013) reviewed the present state of psychiatry in Saudi Arabia. The researchers provided a 30-year old update on the advancements made in the field of mental health care in KSA. Data were collected from a wide range of resources. It was concluded from the study that mental healthcare in KSA has witnessed progress in spite of political, social, religious and cultural challenges. There are some aspects that need immediate attention in this regard. Development in the domain serves as a strong model for different countries across the globe.

Acording to the research conducted by Al-Habeeb, Helmi and Qureshi (2016) there has been tremendous growth and development in the optimal implementation of mental healthcare facilities in Saudi Arabia, but requires additional inputs foe enhanced results. The quantitative analysis was conducted with the help of Mental Health Information Reporting System (MHIRS) that undertakes data collection and delivery of services to the patients. This has been concluded that overall progess has been occurred in community services, infrastructure, medical awareness and training, human resource, legislation, clinical handover and services, promotion activities.

The article by Hickey, Pryjmachuk and Waterman (2016) stated that mental illness grew rapidly in recent days and became the priority for the Gulf Cooperation Council. The researcher selected to local service users for the research to reduce the research gaps.  According to the authors, the local research is very important to understand the situation of that place. The main aim of the article is to review and synthesize the mental health research from Gulf Cooperatio Council. This will provide a clear view on the socio cultural context.

Religion and Spirituality’s Role in Mental Health Care

Dardas and Simmons (2015) stated in their article that mental health services could reduce the burdens of the mental illness. Mental illness stigma is one of the prevalent reasons that seeks the mental health treatment in the negative health consequences. The acceptable things of the society may be unacceptable to the mentally ill people as they cannot accept anything normally and needs quite time to understand. This analysis gives a foundation for the future work in areas of the mental health illness education, diagnosis and treatment.

Mental illness is a serious condition effecting feelings, behaviour and thoughts of an individual and a wide range of conditions are associated with mental illness. The different types of illness effects individuals of all ages and different cultures, ethnicities and incomes. The scenario of mental health status among the population in Saudi Arabia has drawn the attention of social and health researchers who constantly are in the quest for gathering more information on different aspects of mental illness and care provision. It has been found that mental illness is on the rise in the Kingdom of Saudi Arabia, with depression being the most common mental illness. The story of mental health care in KSA has witnessed transformation since its beginning and attempts are being made to adapt to the challenges of the present day context of mental health of the population.

From undertaken researches, it has been highlighted time and again that multi-faceted social, religious and cultural factors influence the access to mental health care services by the individuals suffering from any mental health issue. In this regard, it is to be mentioned that stigma plays a major role in influencing how individuals in the country perceive mental illness and its proper treatment. Moral beliefs act in conjunction with stigma and change the interventional programs are set of managing mental health conditions highly prevalent among the individuals. People often have some misconceptions regarding the cause of mental illness, the most common one being possessions by demons (Jinns). In spite of the majority of the population being educated, such concepts are still prevalent. This implies that there is an immediate need for public education to eradicate such beliefs and notions from the society. Many studies have focused on to the relevance of religion and spirituality with care systems for those who are suffering from mental illness. Religious backgrounds encumber the treatment of mental illness, and spiritual upbringing determines how an individual recognizes the need of getting treated.  Essentiality of integrating mental health care awarenesses into the public has come up from the present research. Against this backdrop, there is still a scarcity of information on how these factors exactly undermine healthcare services in the country. The perspectives of healthcare professionals towards people with mental illness is also a vital factor as it is in their hands to impart education and support the cause. Their attitudes toward people, irrespective of gender, age, and educational and income level, is crucial since patients rely much on the help and support provided by the professionals. The country is making great progress in terms of mental health training and research, but there are still certain areas that are lying unexplored. Investigating in these arenas would bring developments for the country.

From the above literature review, it can be understood that there is a significant gap in literature pertaining to the factors that directly and indirectly impact the mentality and attitude of people in the Kingdom of Saudi Arabia towards accessing mental health services. Not much is known about the driving factors that compel the individuals at large to not access proper health care services when suffering from mental health issues. While some progress has been made to know the reasons why individuals do not want to access mental health services, encompassing social, cultural and religious grounds, much remains to be explored in terms of mental health research.

The proposed study would aim to explore the apparent reluctance of people in Saudi Arabia to access mental health services. The rationale for the study would be to address the gaps present in existing literature relevant to the topic of mental illness in KSA. By addressing the gaps in the literature, the present study would contribute significantly to the important topic of research in the field of mental health.

Research is needed in the country of Saudi Arabia for identifying the individuals with mental health problems, determining the demographic, behavioural and social characteristics commonly increasing and decreasing risks of mental disorders. There is also a need of discovering the most suitable treatment options that individuals of Saudi Arabia are willing to make a part of their lives given the unique religious, cultural and social backgrounds. Research is also needed regarding the mental care providers and the kind of training they need. The proposed research would help in this context and contribute towards the gathering of rich information on all these topics. This information would be crucial for being a guide for the development of robust strategies for mental health care access, and funding of these programs would be made easier. The overall impact would be the adequate fulfilment of mental health needs of the full population of KSA. Understanding the reasons behind hindrance of adequate implementation and utilisation of health care services would also bring changes in the different interconnected components like mental health plans, programs and policies, regulations and legislations that govern mental health service practice and various organisations, systems for training mental health practitioners, social arrangements promoting social participation of people and sociocultural and political environment as a whole. Mental health information system can also undergo drastic changes if the proposed study brings out some valuable facts and figures.

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