AN ARAB PERSPECTIVE
Editors : Ahmed OKASHA (Cairo-Egypt) - Mario MAJ (Naples – Italy)
Co-editors: Aida Seif El Dawla (Cairo-Egypt) - Tarek Okasha (Cairo-Egypt)
World Psychiatric Association –June 2001
q CONTENTS / SOMMAIRE
q Chapter 1
q Chapter 2
q Chapter 3
q Chapter 4
q Chapter 5
q Chapter 6
q Chapter 7
q Chapter 8
q Chapter 9
q Chapter 10
q Chapter 11
q Chapter 12
q Chapter 13
q Chapter 14
q Chapter 15
q Chapter 16
q Chapter. 17
q Chapter 18
q Chapter 19
q Chapter 20
q Chapter 21
q Chapter 22
The fact that all three heavenly religions originated in what rater became the Arab region has colored the culture of this region and influenced the behavior of its population. Seven thousand years ago Ancient Egyptians believed in one God, the after world and that our worldly deeds will bc balanced in the Day of Judgment. This led James Breasted to consider the Egyptian culture as the dawn of consciousness.
In the Arab culture the humanitarian interaction with a doctor is heavily valued , if not more than his or her technical ability or scientific knowledge. Social integration is valued more than autonomy. The family and not the individual is the unit of society, something that Western culture is trying to pursue in this millennium. In many non-Western cultures, native practitioners, to whom modern psychiatry is completely unknown, treat emotionally disturbed persons. Such treatments are frequently the only method available in some cultures, a fact that requires better understanding to clarify the complex ways in which mental illness interacts with culture. Traditional treatments are characterized as culturally compatible (healers are familiar with the cultural value systems of the patients) and holistic (physical, psychological, social and spiritual aspects of healing are integrated). Religion plays an important rote in symptom phenomenology, attribution (God's will) and management in the Arab culture. Islam is the religion of the majority in the Arab region- Islam is essentially geared to a theocratic society, in which the state and the individual are of value only as the servant of the revealed religion.
This book is a crosswalk through the different ways in which Arab culture colors the discipline of psychiatry, starting from its history, to the symptomatology of disorders, to the social factors that color that symptomatology, the impact of culture on treatment methods, foremost psychotherapy and the existing legislation, services and educational bases serving the discipline. It is a collective product of a number of Arab colleagues from seven Arab countries, each from his or her own perspective and experience have presented their insight into the impact of Arab culture on our specialty.
My sincere thanks goes to my colleagues and assistants Dr. Aida Seif El Dawla and Dr. Tarek Okasha without whose help in revising, proof reading and contributing their chapters, this book would not have been finalized. My enormous gratitude goes to Mrs. Jennifer Okasha for her meticulous proof reading of this book.
Prof. A. Okasha
Prof. M. Maj
q SUMMARY / RESUMES
q Chapter 1
§ History Of Mental Health In The Arab World / Ahmed Okasha
CONCLUSION : Mental Health has been identified as an essential component of a person's health in general ever since the time of the Pharaohs. That extent was important enough to place therapy within the divine boundaries of the spiritual and religions. Since those days through the Islamic era to the present day, psychiatry and mental health services have come along way. The development of knowledge, the introduction of pharmacotherapy, the continuos development of neuroscientific diagnostic tools and instruments, did not exclude other actors from assuming responsibility for people's mental health. Traditional healers in our region continue to play a crucial role in being the first line of defense against unexplained psychological symptoms that people fail to place within the domain of medicine. Culture is a major determinant that does not only color the of health and disease, but also colors the disease and determines when and where help is sought. Although we have 22 Arab countries in the Arab League, yet mental health services that arc provided in those countries show several variations. Economic, political, social and cultural factors seem to play a major role in determining the state of the psychiatric profession and the access of citizens to the service.
q Chapter 2
INTRODUCTION: Social Psychiatry comprises all contributions of human interpersonal factors and human togetherness to psychiatry. Cultural Psychiatry is the part of social psychiatry related to the social heritage of shared values, beliefs, attitudes and practices which are passed from one generation to the next. The term transcultural psychiatry is sometimes used to describe social psychiatry in non-Western countries in an attempt to find out why social contributions to psychiatry in the West are not global.
The Arab family is the main social institution that has inputs relevant to clinical psychiatry. It contributes much more than the Western family to mental development, illness behavior, illness pattern and illness management. The roles of schools and out-of-home care institutions are more significant in the West. Recent budget realignments in Western countries drastically compromised their social welfare system, and services for the elderly, the poor and the sick had to be taken over by "someone else". Western mental health professionals rediscovered the role of the family in this respect, which had long been abandoned for the sake of individuation of human beings. The family care, which was phased out through industrialization and communism alike, is now actively re-sought (1).
The Arab family runs the affairs of its healthy and sick members alike. Although extended family households have been largely replaced by nuclear families, the latter have maintained a 'functional' extended family by frequent visits, telephone contacts, business and property partnerships and arrangement of marriages within their bigger family network. The functional extended family provides substitutions for parental loss or absence, mediation in conflicts (including marital and intergenerational conflicts), preferential (nepotistic) employment of kin and help with expenses of health care. The fore- care and after-care of the sick are family responsibilities in Arab countries.
q Chapter 3
§ Epidemiological Studies In The Arab World / Rafia Ghubash
CONCLUSION: Large-scale community surveys are scarce in the Arab world. Despite the available resources that exist in the Arab countries collaborative multi- national cross-sectional and longitudinal studies have not been produced. However, there is lack of reliable epidemiological psychiatric base line data. This is partly related to the very concept of mental disorder itself, which may vary widely in divergent cultures (32), and to the methodological problems of assessment and evaluation. There is scarcity of valid, reliable and culture relevant Arabic psychiatric research instruments. There are doubts about the scales, which were originally designed for use in other cultures, due to problems relating to the linguistics and conceptual equivalence (33). This emphasizes the need for culture relevant psychiatric instruments designed by Arab experts, and tested in various centers in the Arab world so as to agree on final versions. Epidemiological studies in the Arab world should inevitably focus on the health problems commonly encountered in this part of the 'world and on the development effective strategies for evaluation taking into consideration the pertinent ethno-sociocultural influences. Reliable epidemiological data of such local health problems is only the initial step for effective long term solutions. The nature of psychiatric clinical presentation among local patients of this area, and the impact of such presentation in making a diagnosis and on management is another area of investigation. Clinical phenomena like somatisation, which is a local chronic problem leading to prolonged morbidity and negative impact on the available resources and patient's life, is far from being understood and addressed. The response to psychotropic agents, and in which dosages, also seems to be influenced by ethno-socio cultural factors and needs to be looked at. A final crucial point is that no rational planning for future psychiatric services, education and research can be done without a reasonable, relevant psychiatric data base. As psychiatric epidemiology is expected to make substantial contributions toward better understanding of mental disorders more rigorous work that utilizes well defined goals, appropriate designs, valid instruments and the contemporary classification systems in psychiatry is needed. The work that has been done so far should stimulate researchers in this part of the world to conduct further valid and well controlled studies within the domain of psychiatric epidemiology.
q Chapter 4
§ Primary Care Psychiatry / Adel Sadek, Tarek Okasha
CONCLUSION: The increased awareness of primary care physicians of psychiatry is mandatory. It is estimated that 80% of all mental patients seek their help either from the GP or traditional healers. Many studies have shown that depression is under-recognized, under-diagnosed and under-treated by GPs all over the world. The promotion of mental health services especially in developing countries, where human resources are limited, is not through increasing psychiatric beds, or numbers of psychiatrists, psychologists and psychiatric nurses, but by better education and continuos medical education to our primary care physicians.
q Chapter 5
§ Schizophrenia Across Arab Culture / Afaf H. Khalil
CONCLUSION: The future policy of the Arab countries for the management of schizophrenia should allocate more resources, both human and financial, to the provision of mental health services addressed to schizophrenic patients. There is a need for the development of a practical guide specifically tailored for Arab countries to conform to local needs, resources and socioculturel perspectives. A comprehensive management of the problem of schizophrenia in the Arab region calls for the design of an integrated program by policy makers to develop comprehensive mental health policies and legislation which reflect local cultural situations and which respect and protect the human rights of patients with schizophrenia.
q Chapter 6
§ Depression In The Arab World / Y. Amin, E. Hamdi, M. AbouSaleh
CONCLUSIONS: There is a large literature on depression in Arab patients that have accumulated over the years despite the recent entry of modem psychiatry to the Arab World. Unfortunately, research reports are patchy and difficult to compare with each other due to different design and methodology. In some areas like the translation and application of assessment instruments there is a plethora of trials. When it comes to actual comparative research within the same study, the contributions of Arab investigators are minimal. There is an apparent lack of communication between researchers so that at some point there were three different translations of the Present State Examination in its 9th revision in use. More important, the patchy research endeavors makes the drawing of conclusions about the characteristics of Arab depression even more difficult. Still few trends emerge.
Depression appears to be as prevalent if not more prevalent in the Arab culture compared to other cultures. The excess seems at least in part to arise from the willingness of Arab patients to stress their suffering and to somatise it. With that in mind, depression, like the Western variants of it, seems to go more with poverty and other social ailments that have been well documented elsewhere.
Arab patients tend to respond better to open-ended interviewing with plenty of encouragement and revisiting of important areas. The moods associated with the depressive syndrome are either muted or overshadowed by somatisation and irritability. Guilt is not a distinctive feature, and actual suicidal acts are less common though the thoughts are there with high frequency
The special history of the Arab region and its peculiar social fabric created situations in which depression might flourish. These include the rapid process of acculturation that affected certain regions and the aftermath of the tragedies of war in several parts of it. A legitimized form of infidelity taking the shape of polygamy creates unhappiness not much different from that created in women in other parts of the planet.
q Chapter 7
§ OCD: A Transcultural Approach From An Egyptian-Islamic Perspective / Ahmed Okasha
INTRODUCTION. Culture is a matrix that constitutes the background against which we should understand the biological, psychological and social dimensions of mental disorder.
No doubt however OCD has been attracting the attention of researchers in aspects other than its biological nature, especially that of its nosological status, diagnostic criteria and the cultural coloring of its symptomatology.
A syndrome related to OCD has been recognized for more than 300 years (1). Early descriptions focused on different aspects of the syndrome and reflected the prevailing culture of the observer. French phenomenologists emphasized the importance of doubt and loss of will (2,3). The German view focused on the irrational nature of the thoughts, linking it to psychoses (4). Previous Egyptian studies on psychiatric phenomenology have shown a prevalence of culturally determined symptomatology, where religion and prevailing traditions seemed to color not only the clinical picture of the condition, but also the patients' attitudes about their disorder (5-7). All Egyptian OCD patients studied hitherto had religions ruminations and sexual impulses and related issues. Ideas, images, and ruminations were more common among university-educated patients, whereas rituals and impulses prevailed among those of low education. Fears were directed toward diseases, death, madness, germs, and extraterrestrial powers. Also, Egyptian OCD patients frequently presented with symptoms other than obsessions or compulsions, e.g., anxiety, depression, or social incapacity (8).
The introduction of the Yale-Brown Obsessive-Compulsive Scale (Y- BOCS) by Goodman et al. provided a specific measure of the type and severity of symptoms of OCD that is not influenced by the type of obsessions or compulsions present, and thus provides a structured tool for the phenomenological study of OCD symptoms (9).
The present study was performed with the aim of studying the nature and severity of OCD symptoms in a sample of obsessive Egyptian patients and to determine the impact of culture on their symptomatology in comparison to the findings of other studies. An attempt was made to assess the comorbidity with OCD and to investigate the premorbid personality patterns prevailing in the studied sample.
q Chapter 8
§ Trauma And PTSD / Sarnir Qouta And Eyad El Sarraj
INTRODUCTION: Over the past few years, the study of Post-traumatic Stress Disorder (PTSD) has become embedded within a refined topology of childhood traumatic experiences. At the same time, however, this association of PTSD with childhood trauma has been highly criticized. Such criticism has highlighted the fact that focusing on a set of symptoms tends to minimize the child's experience of trauma and violence, that PTSD does not have diagnostic specificity, and that PTSD focuses on specific past events while disregarding the potential that the trauma may be ongoing.
As most research and data about PTSD has been generated in the West, an intense debate has arisen as to whether or not a PTSD model can be applied to non-Westem countries. Those in favor of the application of this paradigm to areas beyond the West cite the experience of many Southeast Asian and Central American refugees who have fallen within the parameters set by the DSM-IIIR and ICD-10 and met the diagnostic criteria for PTSD. Others have similarly argued that a psychotherapeutic approach applying the PTSD model and focusing on the trauma should cut through cultural differences. Furthermore, inasmuch as the PTSD model forces the psychologist to search for psychophysiological and neurobiological abnormalities, it should be independent of ethnocultural factors. That is to say, people anywhere will exhibit the same responses to traumatic stress.
Those opposed to a non-Western application of the PTSD model argue both that the refugee trauma experience is usually protracted and repetitive and that a PTSD perspective pathologies what may actually be a normal psychological process. The latter idea, which suggests that everyone exposed to traumatic stress will develop PTSD, has been rejected by Friedman and Jaranson (1). They cite large-scale epidemiological research done in the United States which shows that many people exposed to trauma do not develop PTSD. Rather, there seems to be a point at which pathological grief is transformed into an affective disorder; for traumatic events that cannot be psychologically integrated, chronic post-traumatic syndrome follows.
q Chapter 9
§ Drug Abuse, In Arab World: A Country Profile Of Egypt / Ahmed S. El-Akabawi
CONCLUDING REMARKS: Reviewing information that pertain to drug use in Egypt and Arab countries, one might draw an insight into that which underlines cultural perspectives and predicts future trends.
1- Compared to developed countries, it is obvious that types of drugs widely used in our part of the world are mainly either central nervous system depressants or hallucinogens. Both point to drug taking in our culture as means of an escape from rapid societal upheaval during a phase of national change and from stability and conservatism to an unknown contemporary modern society. Available models of developed societies are threatening and frightening for a nation that had an historical backlog of civilization. The nation is negotiating an identity crisis hand in hand with challenges of development.
2- Linked to the above point, it is predictable to expect a trend of drug use increase in the cultural context
Basically, the patriarchal-conservative character of societies, in the region, are shaking and one would say fighting the erosion and disintegration brought about by the rapid worldwide contemporary changes. Changes are continuously infusing society which is ambivalent towards them. The patriarchal society produces via its families and cultural organizations, young people who share characteristics that mount to a prototype of Arab Youth.
An Arab young person is basically submissive, suggestible and a follower. Such traits make the youth subculture mainly docile andeasyto rnanage and lead. However, another trait of passive aggression in face of stressing seems to bc a national denominator. During the present phase of transition, one would expect the young to bear the brunt of the confusion. Escapism through drug taking behavior and the often repeated accusation of the young of being careless and not serious enough are probably the major symptoms of whai one could call "Developmental Crisis of the Young" as part of the National Identity Crisis that the whole of the region is negotiating. A decade or more seems necessary to pass through these rough waters. Symptoms, thus, seem to have more chance to increase rather than to disappear.
3- From changing patterns of use, success of law enforcement efforts and the already rising share in the market of licit psychoactive drugs; it is expected that both locally cultivated sativa plant and more illicit manufacturing of addictive medicines would increase to dominate the scene.
4- In Egypt and some other Arab countries, democratization and capitalism
will bring about in their wake a degree of societal polarization and economic problems conducive of a fertile soil for drug use to spread.
5- Priority of provisions to control licit drug dispensary is a must in the next two decades.
6- Prioritization of primary preventive interventions is of paramount importance in a society that is, and will probably, continue to bc, for a few decades, a young population. On the whole, in Arab countries those under 15 years old are about 50%. Concerted rational actions to equip the young with staining, knowledge, and behavior to say "NO" for experimentation are the safeguard for a nation to protect its tendo Achillis.
7- Extension of mental health services to primary health lever and school and university health services is a national need with economic gain at present and in the future.
8- In view of world changes viz. globalization and iinpleinentation of the GATT, the problem of drug use inoves to the forciront as a national security problem for each of the Arab States.
q Chapter 10
§ Child Psychiatry In The Arab World / Amira Seif el Din
SITUATIONAL ANALYSIS: Children in the Arab World constitute around 45% of the total population. General constitution of the families in the Arab World, is the extended families emotionally more than physically, this develops a better bond and support to the family members. It is more prevalent among rural than urban families.
Usually the discipline in the families in the Arab world is in such a way that the parents are overprotecting their children and the children have to obey the order of the parent as a discipline system. This dynamic system raised lack of communication between children and their parents particularly among adolescents as mentioned in the study done by Seif El Din et al. where 57.5% of the adolescent sample confirm the lack of communication between family members (1).
The awareness about psycho-social development of children and adolescents is lacking among the majority of parents where in a study done by Seif El Din et al. (2) using the standardized Arabic version of behavioral checklist questionnaire (B.C.L.) developed by Graham in 1977 (3). This study portrayed the number of pre-school children having behavioral problems were nearly one fourth of the total sample (23.35%) and fifty percent of them were reported to have temper tantrums, followed by sleep problems mainly difficulty to sleeping on their own and over activity.
This study showed disagreement between (B.S.Q.) and (B.C.L.) as regard sphincteric control where Egyptian parents are very strict to exercise their children to control sphincters particularly the bladder and sometimes they use aggressive ways to control sphincter reaching the degree of physical abuse (4).
q Chapter 11
§ Attention Deficit Hyperactivity Disorder (ADHD) / John Fayyad, Maha Sadek, Caroline Cordahi
IN SUMMARY : In summary, the phenomenology and clinical profile of ADHD in Lebanon, and by extension, in the Arab world, can bc easily recognized if the proper diagnostic procedures and tools are used. Multidisciplinary treatment including medication and involving the ADHD subject's school and patents can bc successfully implemented with encouraging results. The use of the stimulant Ritalin in Lebanon is safe as well as effective in targeting the core symptoms of ADHD. Other stimulants should bc introduced and become available to those who do not respond well to Ritalin. Attention must be paid to the comorbid psychiatric conditions often present with ADHD as they do impact choices of treatment.
Much work remains to be done to increase awareness in our schools and in the community about ADHD. Early intervention can avert many of the secondary complications students encounter like school failure, poor peer relationships and low self-esteem. -Early identification can also prevent adolescent outcomes of delinquency and substance abuse.
Advocacy work is needed at all levels to meet these goals and judging by what has been accomplished in Lebanon in the last 1 0 years with Ritalin becoming available, the development of a Ritalin registry at the Ministry of Public Health, the increasing awareness in schools and the formation of the ADHD Association, we can be optimistic about the future and what it holds for children, adolescents and young adults with ADHD.
q Chapter 12
§ Psychogeriatrics In The Arab World / A. Abyad, A.M. Ashour, M.T. Abou-Saleh
INTRODUCTION: The population of the world is aging rapidly. It is currently estimated that more than half (58%) of all people who are 65 years and older live in developing nations. The world's older population experiences a net increase of 1.2 million each month, 80 percent of which occur in Third World nations (1,2,3). It is projected that by the year 2025, the total elderly population will reach 976 million with 72% living in developing regions (2,3,4). Also, as in the west, the growth rate is fastest for the oldest old, those most likely to have chronic diseases and be in need of health services. It is apparent that the problems of the frail elderly and the development of geriatric health programs are international concerns (5). The Arab World will have a rapidly aging population within the next few decades. Many factors have contributed to the increase in the elderly including improvement in living standards, the curbing of communicable disease, and the latest breakthroughs in medical science.
The region is passing through the "Health Transition Phase," which is characterized by an unprecedented increase in both number and proportion of adults and elderly persons. Improvement of health care has been achieved by a combination of technical advances, social organization, health expenditure, and health education (6,7,8,9). Rapid urbanization and industrialization have occurred across Arab countries. The epidemiological consequences of these changes will lead to an increased rate of death from cancer and circulatory disorders. In addition, an increase in chronic disorders of old age and the aging of the population itself will put enormous demands on the health care system. As yet, there is no satisfactory geriatric care available for the elderly in the Arab World. Different countries have started different programs which tend to be rudimentary and fragmented with no programs at the National level (8,9).
q Chapter 13
§ Mental Health Of Women In The Arab World / Nadia Kadri And Driss Moussaoui
CONCLUSION: Women, in developed or under developed countries, have frequent and various occasions of stress, because of different roses and tasks they have to .assume in the society as mothers, spouses, daughters, employees and because of their unequal status as compared to men.
q Chapter 14
§ Social Factors Affecting Women’s Mental Health In The Arab Region / Aida Seif el Dawla
CONCLUSIONS: : When women's position in Arab society is examined it is clear that there are sufficient causes in current social arrangements to account for the surfeit of depression and anxiety experienced by women. Reviewing existing data concerning the prevalence of risk factors to psychological distress in women, requires a serious attempt to attack the sources of female suffering and to provide services that deal with the negative consequences of gender inequality. The social roots of poor health for women, discrimination in employment, education, food distribution, health care and resources for economic development are critical variables that have to be addressed by mental health workers or, shall we say, mental health activists. Those social roots of poor mental and physical health for women are numerous and deeply entangled; hence the strategies needed to address the problem must be multifaceted. There is a necessity to view health and disease as social constructions and not only as biological ones. Often the needs of women are perceived as almost exclusively related to their reproductive roles or their needs are defined in general terms without considering and integrating their own experiences of health and illness so that the health system is able to respond in a culturally appropriate and gender sensitive manner. It is important to reinforce the view calling for a holistic approach to health service provision one that defines health in terms of the sum total of the physical, environmental, social, psychological and political influence on women's lives.
q Chapter 15
§ Psychotherapy In Egypt (An Overview) / Prof Y. T. Rakhawy
CONCLUSION: As previously noted, most of our practice is eclectic. Needless to say that eclecticism is not, or should not be a way of escape from practical or theoretical commitment. lt refers to some holistic responsibility, allowing the conscious and unconscious frame of reference of the therapist to do whatever is useful to his particular patient in a particular time. This is judged by realistic evaluation of practical facilities and objective monitors to judge the march and outcome, both quantitatively and qualitatively.
q Chapter 16
§ Arab Psychotherapy / Wafaa L. Haggag
INTRODUCTION: Throughout history, many authors tried to describe the personality of Arabs, emphasizing certain behaviors and lifestyles that, they thought, represent the national character of the Arabs. Among those authors had been Ibn Khaldoun who is considered the real founder of the science of sociology (1).
Since the Arab culture is very heterogeneous, with characteristics that vary from one community to another, so the validity of a generalized concept like a unitary national character can be- easily doubted. The current trend adopted by anthropologist and social psychologists is to avoid using terms like "national", "ethnic" or "racial" in terms of psychology and psychotherapy. Kardiner et. AI. developed the concept of " basic personality type" that is shared by a group of people in a particular culture. They declared that the concept does not correspond to the total personality of the individual but rather to the projective systems or the value-attitude systems, which are basic to the individuals' personality configurations. Thus, the same basic personality type may be reflected in many different personality configurations (2).
Psychotherapy can be broadly defined as a "talking" treatment in which a trained person deliberately establishes a professional relationship with a patient for the purpose of relieving symptoms. Language, as the main cultural instrument of communication creates meanings in a special way. Spirituality and religion are at the heart of Arabs creating meanings and purpose of living and also the commandments concerning interpersonal relationships, which represent values and expectations different from those round in other societies. So for the issue of psychotherapy we can succinctly use the term "Arab" to denote all peoples of the Fertile Crescent and North Africa who adopted Arabic as their tongue and believe in Islam.
A systematic approach to the interdependence of culture (1) the therapist (2) and the patient (3) should be developed in order to broaden the horizons regarding the heating interpersonal exchange that can be characterized as psychotherapy.
q Chapter. 17
§ Arabic Psychiatric Screening Scales / Omar E.F. El-Rufaie, Tewfik K. Daradkeh
CONCLUSION: Over the past 2 decades, there has been remarkable increases in the number of institutions of medical services, education and research in various parts of the Arab world. Useful psychiatric publications are now emerging, and there are various post-graduate studies and residency training programs which include psychiatric research dissertations in their final examinations. It is interesting to note that psychiatric topics are also chosen for examination dissertations in specialties other than psychiatry, e.g. family and community medicine. It is inevitable that there is continuos need for reliable, Arabic, culture-oriented, psychiatric screening instruments. Psychiatrists involved in research should address the type of psychiatric screening tools which would be appropriate for this area. Specific questions include whether to use transported, translated instruments, or to amend such instruments according to local needs, or to develop entirely new ones. It is obvious that it would be irrational to ignore well-established instruments developed in other cultures, taking into consideration that many phenomena and concepts are common in different cultures. In addition, using locally developed entirely new instruments will limit valid comparability of local findings with other worldwide research results. These points represent only some aspects which necessitate critical, careful evaluation before using psychiatric instruments for the purpose of high quality research in this part of the world. Although all the research experience discussed in this article was in PHC settings, it is felt that it will also be relevant and useful to psychiatric research involving the use of Arabic screening instruments in other settings.
q Chapter 18
§ Influence Of French Psychiatry On Arab Psychiatry / Saida Douki, M. Jamil Taktak, Driss Moussaoui
CONCLUDING REMARKS: The influence of French psychiatry remains strong in some Arab countries and in our view; it has its good aspects. It definitely has a clinical richness, which stiff could serve psychiatry worldwide. It has also a humanistic and somewhat subversive tradition, for it was founded by doctors who were also interested in philosophy. Of course, it is out of the question to either oppose models or defend strongholds.
At a time of globalization, which is overtaking psychiatry as well, the "French cultural exception" is still there and can represent a precious asset. It actually contributes to modulate the irresistible attraction of our discipline towards simplistic explanation of mental disorders by neuroscientific approach, and the exclusive treatment by psychotropic medications. What we are striving for is a universal psychiatry medicine, a human science combining art and technique, shrewdness and rigor ("esprit de finesse et esprit de rigor") and the French tradition can help in this endeavor.
q Chapter 19
§ Forensic Psychiatry And Islamic Law / Kutaiba Chaleby
INTRODUCTION: In order to understand the meaning of insanity in Islamic law, it is important to understand the concept of mental competence and legal capacity of a free Muslim citizen. Competence (ahlia) in Islamic law includes entitlement to rights and duties by virtue of being a human, a state referred to as themma (1). For example, the fetus while inside the mother's womb is entitled to receive an inheritance, carry the father's name, be the subject of a will, receive appropriate medical care, and so on. Competence of entitlement also obliges the individual to fulfill certain duties regardless of his or lier comprehension of these duties. For example, a person of any age or mental function is obliged to pay blood money for a relative who has committed homicide or manslaughter.
In addition to competence of entitlement, there is also competence of performance which involves legal capacity to carry out certain activities or perform a certain task. It is stated in Islamic law that everybody who reaches the age of maturity is mentally competent unless he or she is declared otherwise. The mentally competent possess reason ('agil), are fully responsible (mukallaf) and capable of deliberate intent ('amad) (2). The majn'an lacks reason ('adim al'aqil) and deliberate intent and is therefore liable to interdiction or legal incompetence.
q Chapter 20
§ Mental Health Services In The Arab World / Ahmed Okasha
CONCLUSION: In planning for mental health, we should be guided by the general principles that should guide a formulation of a mental health policy. Such policy should be based on decentralization of service, an integration of mental health policy into the general health policy, comprehensiveness of the policy outcome and equity. People should have equal access to the health care, which dictates an equitable distribution of resources and, maybe, a legislative matrix that promotes the social values and protection of mental patients. Such policies should be sustainable. The main element in securing sustainability is the participation of the stockholders in its formulation. Community and civil society participation in the formulation of their health policies in general and the mental health policy in particular is mandatory to the credibility of such a policy and its support by its target beneficiaries: our patients, their families and the communities in which they live. A mental health policy should target the prevention and treatment of mental disorders and their associated disabilities, ensuring availability of minimal mental health care to vulnerable and underprivileged, the use of mental health knowledge to improve general health care and the application of mental health principles to improve the quality of life (5).
To implement these objectives we should raise the awareness of the population regarding mental health and mental health problems, have a comprehensive data base of mental health morbidity, have a planned budget, train and update available human resources and maybe generate new resources and redistribute our bed strengths. Because of the very tight budgets and limited resources available at this time and as a transitional period, the best plan for developing countries, our region being no exception, is to train and update GPs to look after the chronically ill patient and the families. This will give a better and lasting support and care than in hostels or day hospitals. We have abundant GPs as compared to psychiatrists and as previously mentioned, the more orientation of GPs to mental health and the preference of patients and their families to attend the GPs and the natural course of the referral system and the family role of support can give a better service for mental patients in developing countries than the present system of community care in industrialized ones.
q Chapter 21
§ Psychiatric Education In The Arab World / Mohammed T. Abou Saleh
INTRODUCTION: The Arab world comprising 17 countries occupies no less than 12 million kilometers with a population size of 300 million in two continents. Although apparently diverse its countries share many common features in terms of ethnic composition, history, cultural, heritage, religion, political traditions, social values, customs and most importantly the Arabic language. At the same time a wide variety of political institutions exists and countries vary considerably in their socio-economic development. At one end of the spectrum are the politically stable and rich countries with a steady well co-ordinated socio-economic development; in the middle of the spectrum are stable but less rich countries that have been able to sustain reasonable socio-economic advancement; and at the other end there are poorly - endowed and less stable countries.
The state of medical education including psychiatric education in the Arab world is inseparable from the state of health care, socio-economic development and political stability. Moreover the future of health care and medical education in the Arab region will depend on how it meets a number of challenges which center around the gap that is rapidly becoming a gulf between the socio-economic situation of the richest and poorest countries in the region. More specifically there are challenges of population explosion, poverty, the environment, unemployment, debt and arms imports. In relation to health care there is the important matter of investing in public health which entails re- allocation of public resources, the provision of essential health services, the finance of health between the public and private sectors and the provision of health education to all. Finally and most relevant are the forces of change in medical education: the new biology, emphasis on preventive medicine, community orientation of medical education, medical education that is relevant to the needs of the population, the application of information technology and the drive for excellence in medical education in terms of admission policy, curricula, learning materials, laboratory facilities and direct learning and training in community - based medicine (1).
A landmark development in medical education was the AI-Ain Conference on the Partnership of Health Care Delivery and Medical Education: a Blueprint for Change (Medical Education Supplement 1, vol. 29, 1995). The conference was guided by the Edinburgh Declaration principles identified at the 1988 World Conference of the World Federation for Medical Education. The Conference made recommendations to the Eastern Mediterranean office of the WHO, to countries and faculties of medicine on funding and ensuring essential resources; on reorientation of teachers; specialist training and continuing education of health care professionals; and on medical research. All these recommendations are particularly relevant to psychiatric education in the Arab region with its poorly resourced and planned psychiatric service, variability of its standards for undergraduate and postgraduate medical education and the virtual lack of continuing medical education and development.
The more specific landmark development however, is the establishment of a 'Core Curriculum' in psychiatry for medical students produced by the partnership - of the World Psychiatric Association and the World Federation for Medical Education. The Core Curriculum sets a universal gold standard for undergraduate psychiatry education and will be instrumental in bridging the gap between psychiatry and the rest of medicine and will place it in its rightful place at the heart of medicine contributing to the re-design of the new physician for the third millennium. Underpinning this Core Curriculum is the agreement that psychiatry should occupy a major part of the medical curriculum in view of its generalized approach which stresses the unity of body and mind, the particular utility of its skills to ail medical practitioners and the common occurrence of its problems among patients seen by doctors working 'in ail branches of medicine.
This chapter starts with the historical background of Arab-Islamic medicine and education and includes the results of a survey of psychiatric education in the Arab Region and its implication and refer to important aspects such as the Arabisation of medicine and concludes with elements of an Arab Strategy for psychiatric education.
q Chapter 22
§ Mental Health Research In The Arab Speaking Countries / Elie Karam, Maalouf Wadih
DISCUSSION and CONCLUSION: There are several interesting points of importance that emerge from this study:
First, it is clear that the Arab speaking countries have produced much more than one is led to believe. The search in the electronic databases docs not claim to bc complete due to the fact that many of the published Arab research might not have been traced by the above stated method. In an effort to make the search as exhaustive as possible, an effort was made to contact some of the prominent Arab Researchers in the field of Mental Health to provide us with a list and abstracts of their publications: many, especially those printed in locally printed journals, had not reached the electronic databases. This is a- clear indicator that there is still a wealth of research done by Arab researchers that needs to bc unveiled and indexed properly. Hence a serious attempt must bc made in order to encourage these journals to reach international electronic servers.
Second, the subjects covered are quite varied and the wealth of information becomes apparent upon reviewing the CD-ROM that I.D.R.A.C. has produced.
A further point is that individual researchers have been making the difference in these countries, which speaks for the determination and drive of these "pioneers".
It is hoped that these efforts are coupled with the establishment of research institutions with the funds and the know-how that could benefit from the momentum of these pioneers. It would be interesting to compare, at some time, the productivity of the Arab speaking countries to other countries keeping in mind the following parameter-most, if not all, researchers in the Arab world are primarily clinicians-that is they need to see patients at a rate comparable to psychiatrists in private psychiatry in the Industrialized countries. Judging by the amount of funds allocated to research by the respective Arab governments, it is practically a miracle to see any research at all. On the other hand, the pharmaceutical industry is still relatively shy in involvement in this area of the world although this seems to have been changing.
Document Code PB.0096
ترميز المستند PB.0096
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