“In this great future, you can’t forget your past”
According to the World Health Organization (WHO) Mental Disorders Fact Sheet for 2016, 478.5 million people worldwide exhibit cognitive, emotional, and social impairments (CESI). These impairments include depressive illnesses (350 million), bipolar affective disorder (60 million), schizophrenia and other psychoses (21 million), and dementia (47.5 million).1 This number is an underestimate because it does not include developmental disorders such as autism spectrum disorder and attention deficit hyperactivity disorder. The subsequent impact on healthcare system and society in general is likely to be detrimental. Studies show that Oman, a rapidly developing and demographically transitioning country, has a rising share of its own CESI affected population, but mental health interventions too often do not reach sufferers.2,3 Many Omanis who suffer CESI do not seek care from qualified mental health professionals,4 but seek help from traditional healers. There are many reasons why this might occur and these will be discussed. Notably, reaching out and optimizing help and health care provision are key issues.
A shortage and maldistribution of mental health facilities is a principal concern that Oman shares with the rest of the world.5 This is partly due to logistic reasons given that geographically, Oman has vast expanses of desert dotted with human settlements which are often separated by long distances. According to the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS),6 Oman has 26 outpatient mental health facilities, and human resources working in mental health sector including private practices are 14.2 per 100 000 population. As is often the case in emerging economies, the bulk of these services are located in major urban areas. According to WHO-AIMS, “density of psychiatrists in and around the largest city (Muscat) is 2.42 times greater than the density of psychiatrists in the entire country”. Such maldistribution of services may prevent many Omanis, especially in isolated and rural areas, from seeking help from mental health facilities.
While social stigma towards people with CESI is a worldwide phenomenon, it is stronger in societies that value group harmony and a group mindset.7,8 The development of selfhood is generally dissuaded in favor of harmonious collectivity and cohesion. The opposite spectrum of such traditional value systems are those societies that are based on the western philosophical principle of respect for an individual person with a strong emphasis on individual autonomy.
In collective societies, harmonious conformity to family values overrides any individual needs. Let us consider an example which illustrates how conformity has the potential to override even biological predisposition. Studies show that there are more left handed individuals in individualist than collective societies.9 Collective societies may discourage nonconformity to the extent that budding laterality in early childhood is ‘de-conditioned’. It can be assumed that similar social coercion is likely to have implications on the societal attitude toward people with CESI. CESI sufferers in a collective society face the difficult dilemma of deciding which is less distressing: suffering in secret or enduring being socially ostracized in a community where family cohesion and harmony are paramount.
It is not surprising, therefore, that many Omanis with CESI would shy away from professional mental health care in a formal medical setting. Furthermore, anecdotal and impressionistic observations suggest that traditional healers may partly meet the needs of people with CESI in Oman,10 as mental illnesses have traditionally been believed to be connected to the spirit realm.10 Traditional healers appear to remain as the choice for many Omanis who may suffer from manifestations of CESI.
Traditional interventions may be preferred by Omanis because by their nature they are interwoven in its traditions. In contrast, modern healthcare provisions are likely to be associated with stigma and stepping away from the norm of the traditional milieu. The collective nature of the community may view the CESI as affecting the group not just the individual.7 By externalizing the problem, the traditional healer indirectly acknowledges that the individual with CESI as well as the entire community itself, which has been imprinted with such socio-cultural conditioning would likely assume that the rituals have exorcised the invading spirit. On the other hand, if the individual resorts to biomedical care, this may be interpreted that the illness is endemic in the individual. Such attribution has been suggested to be one of the factors that lead to stigmatization of people with CESI,7 due to the fact that when distress is attributed to intrapsychic conflict challenging the socio-cultural teaching that CESI owe their origin to external forces such as jinn. Instead of rejecting the traditional methods, we may need to study them in their natural settings and see whether any beneficial features could be incorporated into modern healthcare provision.
The presence of CESI among Omanis is often gleaned via international psychiatric nomenclature.11,12 However, CESI are protean and without central features, and often experienced in the socio-cultural context.12 There are indications that applicability of the international psychiatric nomenclature to non-western populations are questionable.13 Studies have indicated that in Oman there is a tendency to use somatopsychic idioms of distress rather than verbalizing said distress. Indeed, the high variability of the CESI incidence found across very different populations and geography suggests that sociocultural or ecological factors play a substantial role in the etiology and expression of CESI. The latest version of the diagnostic manual, Diagnostic and Statistical Manual (DSM-5), has made a laudable attempt at cultural sensitivity 11,14 The extent to which such an undertaking helps Omani CESI sufferers to communicate with their health care providers and the extent to which it is culturally appropriate for the intensely community-centered Omani population is debatable.
In summary, it appears that a constellation of multiple factors seems to discourage many Omanis who may suffer from CESI to seek help from modern mental health facilities. These include a maldistribution of services due to geographical and logistic reasons, social stigma, and cultural idioms of distress. Evidence-based countermeasures are therefore warranted. Firstly, if further scrutiny suggests that there is maldistribution of services, concerted efforts will be needed to train more Omani mental health specialists to meet the needs of people with CESI. Secondly, if the stigma is indeed hampering utilization of services relevant for CESI, nationwide educational measures will be needed to mitigate stigma toward people with CESI. Most importantly, Oman needs to integrate modern methods of diagnosis and treatment with culturally appropriate ones. The role of the family and community should be acknowledged and integrated into modern frameworks that go beyond focusing on the individual but include the wider community. The prevalence of traditional healers and their methodology should be studied with empathy and respect in order to better understand the cultural and religious expectations of CESI patients and their families, and how to meet their needs better. After all, they have had a key role in helping communities for a very long time. In cultures like Oman, an individual focus does not exist but rather it is a wide reaching umbrella, which covers and encompasses the family and its community. As such, social identity trumps individual identity. In approaching mental health treatments in Oman, a paradigm shift is required. Studies are needed to shed light on traditional interventions of Omani society and culture. These could in turn be used to inform how to adjust or modify modern CESI interventions. Traditional methods would complement modern methods, thus, making them more accessible in meeting the needs of the Omanis who may have CESI. Modern methods would be seen as an adjunct rather than a replacement of traditional methods, vice versa. The reasons that traditional healers are so valued in communities should also be studied. Modern methods are rapidly moving towards an interdisciplinary model of collaborative care, which empowers the patient as an active agent in change. One could infer that this is much like a community and family members working together by providing a stimulating environment, which encourages an exchange of ideas. Traditional healers in Oman may also excel in interpersonal skills, which are often described as the foundation of effective therapy and counseling, namely astute observation, empathy and sensitive diagnostic questioning to formulate the problem at hand. Courses and workshops could be organized for interested traditional healers in Oman to complement their skills and to learn from them. Traditional healers might become the first step in the referral process then for CESIs. Health professionals would benefit from training in cultural competency, for example, by traditional healers. Mutual understanding, respect, cooperation, and sharing between the two approaches are likely to ease some of the current deficits in mental health care in Oman.
The author declares no conflicts of interest.
The author thanks Dr. Vlatka Duric for constructive criticisms and valuable comments, which were of great help in formulating the final outcome of this editorial.
- World Health Organization. Mental disorders Fact sheet. 2016 [cited 2017 Feb 11]. Available from: http://www.who.int/mediacentre/factsheets/fs396/en/.
- Al-Salmani A, Juma T, Al-Noobi A, Al-Farsi Y, Jaafar N, Al-Mamari K, et al. Characterization of depression among patients at urban primary healthcare centers in Oman. Int J Psychiatry Med2015;49(1):1-18.
- 3. Jaju S, Al-Adawi S, Al-Kharusi H, Morsi M, Al-Riyami A. Prevalence and age-of-onset distributions of DSM IV mental disorders and their severity among school going Omani adolescents and youths: WMH-CIDI findings. Child Adolesc Psychiatry Ment Health2009 Sep;3(1):29.
- 4. Al Riyami AA, Al Adawi SH, Al Kharusi HA, Morsi MM, Jaju SS. Health services utilization by school going Omani adolescents and youths with DSM IV mental disorders and barriers to service use. Int J Ment Health Syst2009 Sep;3(1):22.
- 5. Charara R, Forouzanfar M, Naghavi M, Moradi-Lakeh M, Afshin A, Vos T, et al. The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013. PLoS One2017 Jan;12(1):e0169575.
- 6. World Health Organization - Assessment Instrument for Mental Health Systems (WHO-AIMS). Who-Aims Report On Mental Health System in Oman. WHO, Oman in collaboration with WHO, Regional Office for Eastern Mediterranean and WHO, Headquarters [cited 2017 Feb 11]. Available from: http://www.who.int/mental_health/who_aims_oman_report.pdf.
- 7. Al-Adawi S, Dorvlo AS, Al-Ismaily SS, Al-Ghafry DA, Al-Noobi BZ, Al-Salmi A, et al. Perception of and attitude towards mental illness in Oman. Int J Soc Psychiatry2002 Dec;48(4):305-317.
- 8. Al-Adawi S. Adolescence in Oman. In: Jeffrey Jensen Arnett, Editor. International Encyclopedia of Adolescence: A Historical and Cultural Survey of Young People around the World (2 Volume Set). New York: Routledge; 2006. p. 713-728.
- 9. Porac C. Laterality: Exploring the Enigma of Left-Handedness. New York; Academic Press; 2016. p. 120-121.
- 10. Al Asmi A, Al Maniri A, Al-Farsi YM, Burke DT, Al Asfoor FM, Al Busaidi I, et al. Types and sociodemographic correlates of complementary and alternative medicine (CAM) use among people with epilepsy in Oman. Epilepsy Behav2013 Nov;29(2):361-366.
- 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed.). Washington, DC: American Psychiatric Association, 2013.
- 12. World Health Organization. The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva, World Health Organization; 1992.
- 13. Al-Adawi S, Jaju SS, Al-Zakwani I, Dorvlo AS. Culture to Culture Fatphobia and somatization. In: V. R. Preedy, R. R. Watson, C. R. Martin (Eds.), International Handbook of Behavior, Diet, and Nutrition. New York: Springer; 2011. p. 1457-1473.
- 14. Caraballo A, Lee JR, Lim RF. Applying the DSM-5 Outline for Cultural Formulation and the Cultural Formulation Interview. In: Russell F. Lim, editors. Clinical Manual of Cultural Psychiatry. 2nd ed. Washington: American Psychiatric Publishing; 2015. p. 43-76.