Changing attitudes toward mental illness, treatment in Saudi Arabia

JEDDAH: Stigma toward mental health is something many Saudis still face, and can be measured through their reluctance to seek help, their inability to talk about their issues or to admit there is something wrong.
According to Saudi psychiatrist and cognitive behavioral therapy consultant Haifa Al-Gahtani, things have drastically changed in the past 20 years.

“I remember when I first began my career, people would cover their faces; even male patients would use their headpiece (shemagh) to cover their identity. Nowadays, in my center, people walk freely through the door and ask for a consultation,” she told Arab News.

She added: “The new generation is already very open about seeking treatment, and part of their openness is due to increased awareness.”

She said the prevailing attitude is not ideal and could be improved, but is much better than before. People have been using the internet to stay connected and read more, realizing that mental problems are not different from physical ones, she added.

With nearly 20 years in the field of psychology, Al-Gahtani has witnessed people who believe in and sympathize with victims of evil eye and envy — commonly believed in the Arab world — yet dismiss those with mental illnesses without compassion.

“Culturally, the evil eye and envy are accepted, but many people look at mental illness as a weakness of religious belief and weakness of personality,” she said.

The psychiatrist believes that everyone can play a major role in decreasing the stigma further through education in schools, colleges and workplaces.

Al-Gahtani believes that the stigma can disappear through people embracing their mental health issues and not being afraid to speak about them. 

“You don’t have to go everywhere and tell people you have depression, but at the same time, if people have depression, they need to perceive that it’s an illness and they can seek treatment and it is treatable,” she said, adding that encouraging others to get help is key.

Why is psychotherapy uncommon?

The notion among people is that a doctor is only meant to prescribe medication; it is evidence-based and researched enough to be proven efficient in treating many mental health issues, but according to Al-Gahtani, it is not always the best course of action due to “cases not responding to medication.”

“A lot of people have misconceptions about medication, that it will cause dependency, or destroy the patient’s brain. These are all myths. There are a few that can be addictive, but these are rarely used in practice. As long as a doctor prescribes the medication, there should not be a dependency on them,” she said.

There are some cases where it is crucial for the patient to be medicated in order to help them concentrate; their level of energy and motivation is very low and therapy loses its efficacy, she added.

With psychotherapy, therapists have guidelines for treatment that help them conclude the patient’s diagnosis, leading to the necessary course of treatment.

“After sitting down with the client, sifting through a diagnosis, we set up a treatment plan, which usually is based on the severity of the patient’s illness. For instance a person with depression, mild, moderate or severe — we have set guidelines that direct us on the route to follow. For mild and moderate cases, international guidelines state that psychotherapy which is either cognitive behavioral therapy, interpersonal therapy, or psychodynamic therapy has proven to be efficient to treat them,” Al-Gahtani said.

The reason for the decline in psychotherapy in the Kingdom, she said, is that the number of trained therapists is low compared with the number of people seeking help.

Most treatment courses conclude when medication is prescribed. Therapy needs time and effort, while being costly, with a single session costing from SR400 ($106) to SR800, depending on the therapist, she said.

Due to that, and lack of awareness, many people think they cannot afford therapy sessions.

“Thankfully, a recent mandate that includes chronic psychotherapy in medical insurance has been modified, when it used to only include acute mental health issues. Insurance companies would settle a medical bill for pills that cost SR100 per month and that would be it. But with costly psychotherapy sessions, as the doctor prescribing them, I have to write a strong statement to ensure that insurance covers my patient’s expenses for their sessions,” she added.

Cognitive behavioral therapy (CBT) is the most popular in the Kingdom.

By default, people go for cognitive behavioral therapy because of its availability in Saudi Arabia, said Al-Gahtani. For most mental health problems, in particular mood disorders, depression, anxiety, obsessive-compulsive disorder, phobias, it is a very effective course of treatment, but CBT is not for everyone.

According to the CBT therapist, consultant and trainer, CBT entails a patient coming in to discuss their issues with the therapist, who in turn helps them set goals.

After every session, the patient has an assignment to complete when they get home, writing thoughts, feelings, talking about a situation that made them angry, anxious or disappointed, depending on the issue they had discussed with their therapist.

From there, they come back and discuss their assignment with the therapist, analyze it and try to look at it from a different perspective, see if the set goals are achievable, and if they are, they move on to the next target, and so on.

“An example is a person who has a fear of public speaking, giving presentations or speeches to a crowd; what a CBT therapist does is ask them to write every situation that makes them anxious, praying in the mosque, speaking in a meeting, saying no, starting from the least worrying to most. We go through directing exposure gradually until it goes away, their confidence increases, and so on. It is fully dependent on the patient’s commitment to the work needed between each session,” Al-Gahtani said.