In the Middle East, learning from and respecting the culture of the population we are working with is a necessary step that will help build trust, understanding, and acceptability of evidence-based mental health interventions. Culturally informed conversations with Syrian refugees, for example, will help them become more aware of the treatment approaches available to them and give them more agency in their treatment. This will also support the development of new treatment programs better suited to their needs.
HeadHealth (www.HeadHealthGlobal.com), an organization I founded in 2016, is dedicated to funding, designing, and implementing quality, evidence-based and culturally appropriate mental health services for some of the world’s most vulnerable people. The organization strongly rejects the idea of implementing a Western-style treatment program that does not adequately take into consideration the needs and culture of the local populations being served – for example, work with war-traumatized Syrian children living in Jordan.
Mental health programs must align treatment modalities with the cultural values and clinical needs of a given person or population. Making relevant adaptations to traditional (Western) psychotherapeutic treatment modalities for global populations will help reduce the fear, uncertainty, and uneasiness with mental health treatment in general.
I would like to describe how certain aspects of traditional psychotherapy could be adapted for Middle Eastern populations using HeadHealth as an example.
Addressing the Language Barrier in Mental Health Services
Often, mental health providers from international organizations lack the language skills necessary to communicate effectively with consumers of mental health services abroad. The utilization of an interpreter and the general lack of cultural understanding around symptomology, diagnosis, family, and societal norms greatly affect the development of the all-important therapeutic relationship between provider and consumer. There should be no dependence on translators during interventions. HeadHealth’s culturally and linguistically trained US-based clinical team empowers local professionals to speak with children in their own language.
Involving Syrian Families in Mental Health Treatment
Studies have indicated that many individuals from Middle Eastern backgrounds are suspicious of seeking treatment that is culturally incongruent. Emphasizing the normative and traditional role of family and — better yet — actively involving and incorporating family members in treatment activities, enables HeadHealth to overcome some of the limitations of traditional Western psychotherapeutic approaches. This is typically preferred by the non-Western, community-oriented populations we work with.
Many studies indicate that in the Middle East, individual “talk-therapy” is often perceived to be contrary to the cultural norm that insists private family affairs not be discussed with outsiders. HeadHealth’s current program does not engage consumers in individual therapy but instead emphasizes community, group, and family work.
Western approaches emphasize the individual. HeadHealth invites the parents, siblings, cousins, friends, aunts, and uncles to engage with HeadHealth’s materials to reduce the mental health implications of war trauma for children.
Fakhoury on his 2016 Visit of Jordan
“I saw thousands of Syrian children who were devastated by the loss of family, community, and country. The cry of one inconsolable Syrian child searching for the parents, siblings, and friends he knew were no longer alive haunts me to this day.”
Gender and Psychology in the Middle East
HeadHealth recognizes that what is socially acceptable about gender interactions in the West may be far from acceptable in some communities in the Middle East. Many families and communities in the region may not feel comfortable with a female family member engaging with male service providers and vice versa; therefore, HeadHealth utilizes the expertise of both female and male providers. Being aware of differences between Western and Middle Eastern cultures may help alleviate unnecessary tension and may help the mental health program become more approachable to certain communities.
HeadHealth is not political and is not affiliated with any religion. HeadHealth emphasizes an organization-wide culture that stresses the need for its entire staff to respect all religions. Islam has penetrated almost every aspect of life in much of the Middle East – even in the lives of Middle Eastern people who are not Muslim. Disrespecting Islam will almost certainly influence the therapeutic alliance between a service provider and consumer in much of the Middle East and will likely add to any existing suspicion of mental health treatment and services.
Several studies suggest that many consumers in the Middle East prefer an authoritative and directive style from their treatment providers. In the current program, HeadHealth has implemented an approach aligned with this preference. The consumers’ need to feel confident in the expertise of their provider is met without employing tactics that promote an all-powerful image of the provider.
HeadHealth is concrete in how it communicates to consumers about the role of each treatment activity and what each treatment activity targets. HeadHealth avoids using unnecessary clinical jargon and other languages that might hinder the all-important process of engagement and collaboration with consumers.
Mental Health Stigma in the Middle East
It is common for people in the Middle East to engage traditional healers, religious leaders, or family members before seeking out formal psychotherapeutic services. Although Western and non-Western mental health treatment approaches do not always complement one another, it is crucial to respect what individuals and families want. Building a bridge of respect and curiosity between even seemingly contradictory treatment approaches is a valuable tool that helps HeadHealth better understand the needs of the diverse populations it serves and helps break down the stigma that prevents many from accessing its crucial services.
All images used in HeadHealth’s clinical material are sensitive to the cultural and societal norms that dominate the region where we are working. For instance, perceived intimacy between males and females (holding hands, being alone in a room, etc.) will not appear in any of the material.
The trauma-informed children’s book incorporates images depicting immediate and extended families and communities rather than only individuals. For example, we are working in Jordan, where the scenes depicted in the clinical material are relevant to the Syrian children who live there.
These culturally and linguistically appropriate strategies also have implications for Western mental health professionals who want to work effectively with immigrants from the Middle East. With millions of refugees bringing their war trauma with them, Western practitioners must be well prepared to provide them with effective mental health interventions.