“In life, almost everything is a performance. The person we are with ourselves, our family, and friends is not always the same. While we are playing all these parts, sometimes we fail to notice how our own struggles affect us.”

Twenty-four-year-old Ally Salama has made a name for himself as a devoted activist in the mental-health cause. He certainly lives up to his title as the “Middle East’s Mental Health ambassador”, and his goal is to put the Middle East and North Africa (MENA) region on the mental-health map.

Through his initiatives, such as Empower House and EMPWR magazine, Salama sparks conversations while outlining tangible actions young activists can take. EMPWR is the Middle East’s first online mental-health magazine and is part of the growing number of initiatives trying to change how Arabs perceive, discuss, and treat mental-health concerns.

But before Salama embarked on his journey towards societal mental-health awareness, he had to address his own struggles.

They began when his family had to move from Egypt to the UK after they experienced bankruptcy. “It was definitely a huge change in my life and completely transformed it,” he said. Later on, Salama was able to move to Toronto in Canada, but there he experienced issues with fitting in and began fighting his own private battles.

His family struggled with growing financial concerns, and they had trouble adjusting to life in a new country. Matters worsened when his grandfather was diagnosed with terminal cancer, passing away not long afterwards.

As a teenager, Salama started to use exercise as a mental-health outlet. He is a former pro-athlete and is well aware that sports and exercise do not always have a linear relationship with mental health.

“I used to swim a lot at the time and was very good at it, but the idea of being athletic while dealing with mental-health struggles was shocking to me,” Salama said. “Now my relationship with my body is a lot healthier, and I don’t do exercise out of concern with how I look. These days it really is just a process of self-love,” he added.

He noted how others had noticed that his attitude and behaviour had changed but had no ideas it was because of his depression. “It had reached the point when some people even thought I was on drugs, but really my depression was just beginning to visibly show,” Salama said.

However, one point Salama comes back to is that he knows that he was privileged in being able to move to Toronto where mental-health services are more widespread and therapy is embraced. “Though my diagnosis did not come right away, I was lucky when I got diagnosed with depression at 17. It saddens me when I see how people in Egypt do not often have the same opportunities which they equally deserve,” he added.  

Salama now lives in Dubai where he continues to raise awareness about such issues. He believes that many barriers to mental-healthcare and therapy are deeply rooted in how the Middle East views mental illnesses.

MENTAL ILLNESS

Contrary to what some people may believe, mental disorders are fairly common among all populations.

The World Health Organisation (WHO) estimates that “close to one billion people are living with a mental disorder, three million people die every year from the harmful use of alcohol, and one person dies every 40 seconds by suicide. And now, billions of people around the world have been affected by the Covid-19 pandemic, which is having a further impact on people’s mental health.”

A 2020 study published by the US Journal of Community Health included a sample of 510 adults from Egypt’s general population. “About 211 (41.4 per cent) noted that they had suffered a severe impact [from Covid-19]. There was an increase in stress from work in 174 (34.1 per cent), financial stress in 284 (55.7 per cent), and stress from home in 320 (62.7 per cent). Half of them felt horrified and helpless, in 275 (53.9 per cent), and 265 (52 per cent) cases respectively, while 338 (66.3 per cent) felt apprehensive,” the study said.

Rita Kallini, an Egyptian-Canadian clinical psychologist, told Al-Ahram Weekly that the stigma of mental illness in Egypt has only really got better in regards to certain types of conditions and disorders. “Disorders that still really have a high stigma are bi-polar disorder and schizophrenia. People with schizophrenia in particular are often simply called ‘crazy’,” she said.

The limited studies on schizophrenia in the country also point to that consensus. A 2020 study from the Egyptian Journal of Psychiatry found that in a sample of 300 patients with various disorders “43.3 per cent had reported being victimised in the past 12 months.”

It was found that “all victimised patients were subjected to emotional victimisation; however, patients with schizophrenia were exposed to higher rates of physical victimisation (93.3 per cent) and miscellaneous victimisation (73.3 cent),” the article said.

A 2014 study in the Frontiers in Psychiatry noted that “the stigma seems to be particularly harsh in relation to schizophrenia.” It found that in the governorate of Ismailia, “64 per cent of general practitioners (GPs) thought that patients might become dependent on psychotropic medication and 11 per cent avoided prescribing them.”

Concerning the family members of individuals who have received the diagnosis of schizophrenia, “75 per cent believed antipsychotic medication led to addiction, and 73 per cent of people working in local media said they would probably be afraid to speak to someone with schizophrenia,” the article said.

The results also showed that “66.6 per cent of medical students have refused to work with a person known to have a mental disorder, and 81 per cent of secondary school students considered people suffering schizophrenia to be dangerous.”

Certain disorders thus still face discrimination, and tolerance still has a long way to go. However, seeing a therapist is not considered as controversial as it once was in Egypt. Though a person sharing that they are seeing a therapist may raise some eyebrows, conversations surrounding therapy are occasionally less about stigma and more about general misconceptions.

“Everything still has stigma, but people are being more open about depression and anxiety,” Kallini said.

People also often do not know what to expect from therapy. The goal of a therapist is not to “solve” their clients’ problems, as no therapist can claim to have the power or even the right to try to do that on their own. Instead, it is to guide clients through their own struggles and complex emotions.

“People are often surprised to realise that a therapist’s role in a client’s first session is to listen much more often than speak. We conduct full assessments, ask about history, family, relationships and why they are here today. We do our best to get the whole picture before diving into anything,” she added.

While the general stigma of depression, anxiety, and therapy has got better, other issues still stand in the way besides just raising general awareness, however.

CURRENT CHALLENGES

Accessibly and affordability issues exist in care services besides therapy.

Twenty-six-year-old Nazli Al-Leithi is a learning support specialist who uses her platform “A Different Story” to raise awareness of disability rights in Egypt.

“We tend to forget that everyone has a different story to share — a different life, a different challenge. Storytelling helps us all highlight these differences, and it can have an incredible impact on how we change our attitudes and mindsets. There is no denying that, as a global community, we have trouble accepting specific kinds of difference,” she said.

Through her podcast and Instagram page of the same name, Al-Leithi holds engaging conversations with disabled people and activists. Though disability and mental illness mean two very different things, disabled people often suffer as a result of bullying and public indifference.

Al-Leithi initially worked as a corporate consultant in the MENA region, but later shifted careers to the special educational needs and disability field. “While I immensely benefited from being part of the corporate world, I quickly realised that I wanted to do something that would give me more personal purpose. Consequently, I obtained my MA in Special and Inclusive Education from University College London,” Al-Leithi said.

“I now work with children with a range of developmental disabilities and learning difficulties with the hope of developing their skills, strategies, and self-esteem in order to cope in an academic environment,” she added.

“We need to make services more accessible for lower socioeconomic groups. This can only happen through government funding, a clearly allocated budget, and large national campaigns. Just like there is a drive to raise money for the Children’s Cancer Hospital or the Ahl Masr Burns Hospital, it would be good to see similar initiatives for special educational needs services for lower socioeconomic backgrounds,” Al-Leithi said.

“Research has shed light on academic, social, infrastructure, and healthcare exclusion. Families with a child with severe, profound, or multiple learning difficulties report adjustment difficulties, greater financial and caregiving burdens, and higher levels of stress than families with typically developing children,” she explained.

“Families are turned away all the time with a ‘we lack the resources’ or ‘your child is too challenging’ excuse,” she added.

A common thread that runs between these problems is how the stigma of difference is still out there and how people with disabilities might end up having serious mental-health struggles because of public indifference, discrimination, and even outright bullying.

“Teachers may find it difficult to identify children with learning difficulties in their classroom and so they go unnoticed and difficult behaviours arise as a result. Socially, individuals with disabilities may find it harder to make friends, can be bullied or taken advantage of, and excluded from group activities,” she explained.

“To me, the most fundamental thing that needs to change is society’s understanding of disability. We need to understand that we are the ones that disable others by refusing to cater for their needs in both their physical and social environments,” Al-Leithi said.

“If we move away from considering disability as a personal deficit or shortcoming, we have already done half the work,” she added.

“In terms of stigma and prejudice, people may view disability as a personal tragedy, as something that needs to be cured or prevented, as a punishment for wrongdoing, or as an indication of the lack of ability to behave as expected in society” Al-Leithi said.

Organisations often hesitate to hire disabled people or end up excluding them from active participation. This way, disability inclusion might seem to exist in many companies, but only really on paper.

“This social discrimination also extends to a lack of employment opportunities. While there is a five per cent employment quota for individuals with disabilities in private Egyptian companies, many employers pay a nominal wage to incentivise those employees to stay at home,” she added.

SERVICES

More and more grassroots organisations like Helm and Zayee Zayak work hard at providing such children and adults with employment facilitation, support, and activities.

Bur financial support and emotional care in Egypt are generally hindered by a lack of awareness and accessibility.

Many of the organisations involved in offering support are not-for-profit services or NGOs and offer whatever help they can to people in need. But this is often hard to accomplish as the government has yet to present long-term and truly sustainable solutions for those looking for quality mental-healthcare.

The stigma has only really got better to the extent that people at the ‘breaking point” of their mental health start to tentatively consider the possibility of therapy. Even then, many struggle to see therapy in Egypt as a serious option rather than an unattainable dream.

However, it is not just affordability concerns that prevent people from getting help. Misconceptions about other forms of mental-health support, such as medication, continue to make many people uncomfortable.

Nayla Grace is a psychiatrist who has frequent conversations with her clients regarding the fear of medication. “Unfortunately, there is a lot of bad press about mental-health medication and misinformation that I work a lot in trying to correct and psycho-educate my clients,” she said.

Medication is one of the topics people tend to shy away from, partly due to a cultural mistrust of any form of mood-altering psychiatric drugs. Another cultural belief is that sometimes people should suppress emotional struggles instead of seeking help.

“One of the most common questions is ‘will I become addicted?’ Antidepressants are one of the most commonly prescribed medications and are not addictive per se; but having said that, anti-depressants can cause what we call ‘discontinuation syndrome’ and that’s different from withdrawal syndrome,” Grace said.

“This means that when stopped suddenly, your body can experience unpleasant side effects that are different from medication that can cause physical dependence,” she explained.

“Medications that can cause physical dependence, meaning your body gets used to them over time, are those that are used to relieve anxiety. We are always very cautious when we use them, so we use them for a maximum of about two or three weeks because people can become dependent on them,” Grace said.

“It is also important to note to never stop taking medication suddenly. It should always be done gradually and under medical supervision,” she explained. “It does often take weeks until clients realise that medication is an important part of treatment. It not the only part, but it is important,” she said.

Apart from topics that hold a stigma, there are also groups of people and whole demographics that are often left out of public mental-health discussions in Egypt. Salama is particularly concerned about the lack of conversation surrounding mental health and men in the Middle East.

When it comes to mental health in boys and men, even well-meaning activists can sometimes neglect to broach the topic. The problem exists worldwide, but it is of great concern in Egypt where men are regularly expected to hide their emotions.

In Salama’s life, his ties with the men in his family were marked by love but also by emotional barriers. “My father was a great man who unfortunately passed away when I was young. I’ll always love him, but I also regret the fact that we could not have deeper conversations together,” he said.

“My grandfather was always a very strong and physically active man, but when he got older he did not want people to see him in his weaker physical condition. Like many men, he was concerned about upsetting others and showing vulnerability; he wanted people to remember him as he was in healthier days,” Salama added.

He emphasises the value of noticing potential problems such as self-esteem and body image issues and what patterns might lead to them or at least signify their possible presence.

 “I look back at the way I used to exercise and do sports – back then the way I did it wasn’t healthy. I often had intense workout sessions even several times a day,” he said.

“I think of how a lot of men still think it’s fine to push their bodies to the limit when exercising, and I also sometimes wonder about the high number of gym subscriptions by men, or why some try and completely change their body when they get married,” Salama added.

Of course, getting in shape is completely fine, but there is a value in examining the motivations behind intense workout sessions and noting if these activities are ever a result of societal pressure.

TANGIBLE SOLUTIONS

In terms of affordability concerns for therapy, unfortunately many clients do not always have a direct way of reducing session fees.

But a common misconception is that therapists will not try to accommodate people with financial concerns whenever possible. “As much as an issue as affordability is, therapists are willing to compromise and accommodate. In my opinion, if anyone wants to see a therapist they should schedule an appointment and honestly talk to them about it and see if they can accommodate,” Kallini said.

A few independent not-for-profits have also taken it upon themselves to help people find more affordable therapy options.

“Lilac is Real” is one great example of this, as it connects people to affordable therapists through the use of a database of professionals. The organisation periodically offer discounts through their service, which can be accessed through a Google form on their Instagram page. It also makes sure to be transparent about which mental-health centres they have interviewed and publicly posts transcripts of their interviews.

A professional help database is also available at all times on their page for people who want more information about therapy options around the country.

A concern many mental-health advocates have is how mental-health initiatives seem to crop up from time to time, but rarely grow as strong long-term services. “Having a business plan is so important, and mental health is not separate from entrepreneurship. On the contrary, social entrepreneurship is where people can make ideas into businesses that have a long-lasting impact,” Salama said.

“It is important that young people focus on their strengths and use them for activism. If someone likes engaging and really learning from people, even creating a page or podcast can help educate those interested in learning more,” he said.

He also sees the value of online therapy in helping people work through complex emotions and issues. “There are so many areas in Egypt that don’t have accessible therapy services, but research has shown that online therapy can really be an affordable alternative,” he said.

“Shezlong” is a leading service in affordable online therapy. While services such as the Dr David George Psychiatry Centre and Al-Nadeem Centre offer affordable options, many such centres are also transitioning to being partly or fully online during the Covid-19 pandemic.

Halfway through his podcast “Empathy Always Wins”, Salama made the decision to have his conversations with advocates in Arabic in order to reach a wider audience. “I think that many of the sources on mental health in Egypt are written in English, and we definitely need to connect with Egyptians in our own language,” Salama added.

He wholeheartedly believes it is younger people who will drive the mental-health revolution, and likens public ignorance of their role to the beginnings of the 2011 Egyptian Revolution.

 “As a country, we are now proud of how young people transformed Egypt, but at first many saw them as no more than kids. Now it is they who are making a change,” he said.

An issue many therapists have concerns about is health insurance. Most therapists want their services to be affordable for clients, but due to the job’s demanding nature and the expensive cost of degrees and training (often abroad), therapy can be more expensive than other healthcare services.

“One thing I want to see change is the affordability problem. I want to see insurance cover things related to mental health because so many people in the country are suffering and they do not have the money to get their own medication. Even government care can be sub-standard and that’s problematic,” Kallini said.

“I would also like to see mental health included in the curriculum just like physical health. People should be raised to know what mental health is and not be surprised to discover its value only once they’re out of school,” she added.

Mental illness in Egypt continues to be a problem that too often gets swept under the rug. Expensive fees, limited cultural education, and a lack of sustainable healthcare services are the main barriers standing in the way of the mental-health revolution.

Yet slowly but surely, a silver lining is growing clearer as initiatives by young activists point to a more promising future for mental health.

*A version of this article appears in print in the 9 September, 2021 edition of Al-Ahram Weekly.