Barriers To Delivering and Acc

BARRIERS TO DELIVERING AND ACCESSING MENTAL HEALTH AND FAMILY
THERAPY SERVICES IN THE UNITED ARAB EMIRATES: PERSPECTIVE OF MENTAL
HEALTH CLINICIANS
Dissertation presented to the Faculty of the
California School of Professional Psychology
Alliant International University
Irvine
In partial fulfillment of the requirements of the degree of
Doctor of Psychology
by
Saad Omar Alkhanbashi
Approved by:
Rajeswari Natrajan-Tyagi, Ph.D., Chairperson
Manijeh Daneshpour, Ph.D.
Sean Davis, Ph.D.
April 2018

ProQuest Number: 10827839

All rights reserved

INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.

ProQuest 10827839

Published by ProQuest LLC (2018 ). Copyright of the Dissertation is held by the Author.

All rights reserved.
This work is protected against unauthorized copying under Title 17, United States Code
Microform Edition © ProQuest LLC.

ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346
ii
DEDICATION
I would like to express my love, appreciation to my family, my mother, my father, my
sisters and brothers, my nieces and nephews for their support and love throughout this long
intellectual journey. I felt the unconditional love and support every single day.
To my sister, Aisha’s soul. You are with me everywhere I go. You are in my heart. I love
you.
.‫ ﺭﺣﻴﻠﻚ ﻋﻦ ﻫﺬﻩ ﺍﻟﺪﻧﻴﺎ ﻻ ﻳﻌﻨﻲ ﺇﻻ ﺃﻧﻚ ﺳﺘﺒﻘﻴﻦ ﻣﺨﻠﺪﻩ ﻓﻲ ﺭﻭﺣﻲ‬.‫ ﺳﺘﺒﻘﻴﻦ ﺩﺍﺋﻤﺎ ﻓﻲ ﻗﻠﺒﻲ‬.‫ ﻋﺎﺋﺸﺔ‬،‫ﺇﻫﺪﺍء ﺇﻟﻰ ﺭﻭﺡ ﺃﺧﺘﻲ ﺍﻟﻐﺎﻟﻴﺔ‬
To my sister, Wafa, who instilled in me, since my early childhood years, the passion for
learning and the desire to chase my dreams.

iii
AKNOLWEDGMENTS
I would like to express my deepest gratitude to everyone who stood by my side and
supported me throughout my journey in attaining and completing my doctorate degree in
psychology-marriage and family therapy. I would like to express my gratitude to His Highness
Sheikh Khalifa bin Zayed Al Nahyan, the President of the United Arab Emirates (U.A.E.) and
Ruler of Abu Dhabi and to Sheikh Mohammed bin Rashid Al Maktoum, the Prime Minister and
Vice President of the U.A.E. and Ruler of Dubai. I would like to thank the government of Abu
Dhabi for sponsoring me and believing in me for all the years I have been here. I would like to
thank my sponsors at Abu Dhabi Educational Council for their unconditional support. I would
also like to extend my thanks to the staff at the U.A.E embassy in Washington D.C. and the
Consulate General in Los Angeles for their guidance and support.
I would like to thank my committee chair, Dr. Rajeswari Natrajan-Tyagi, for always
being close by myside throughout this journey. Her support, love and passion for me and for the
field of marriage and family therapy have made my journey that much more enjoyable and
memorable. Thank you for providing me the chance to give back to my community, my people,
and my country in ways I never thought possible. Many thanks to Dr. Manijeh Daneshpour for
her support, feedback and for allowing me the chance to make my research more culturally-
sensitive. I would also like to thank Dr. Sean Davis for his support and encouragement.
I would like to thank Professor Fatima AlDarmaki, dean of student affairs at Zayed
University in Abu Dhabi, who went out of her way to help and support me throughout my
journey. Dr. AlDarmaki was always accessible and available for me whenever I needed her. Her
valuable feedback made my research applicable in the UAE.

iv
I would especially like to thank my family for their unconditional love and support during
this journey. I would like to thank my father for always uplifting me and showing me the light at
the end of the tunnel. I would like to thank my mother for her warmth, and unconditional love
throughout my intellectual journey. I would like to thank Maryam, my stepmother, for her
support and unconditional love. I would like to thank my sisters (Alya, Fatima, Wafa, Maha,
Yasmeen and Hind) for providing great support and love throughout this intellectual journey. My
sisters are my life, and without them I would have not been able achieve my academic goals. I
would like to thank my brothers (Salim, Mohammed, Abdul-Majeed, Abdul-Rahman, Abdul-
Aziz, Abdullah and Hashim), for believing in me and for being reliable and dependable
whenever I needed them. My dream of fulfilling the greatest academic achievement would have
been impossible without my family’s support.
I would love to extend my thanks to my amazing friends here in the US, who have been
my surrogate family away from home. Thank you for always being close to me and for loving
and supporting me unconditionally. Knowing you and being close to you have transformed my
life to the better. Special thanks to my amazing friend, Nancy Le, who embraced me and loved
me from the first day I arrived to California as an international student. Many thanks to Manuel
Zublena, for having faith in me and for always supporting and uplifting me.
v
ABSTRACT
The United Arab Emirates underwent major transformations in the last four decades. The country
went from impoverishment to lavish wealth within a short time. The country’s economic
advancements alongside the relatively liberal policies and openness has brought people from all
over the world to work and live in the UAE. This sudden transformation and openness may have
increased the prevalence of mental illness in the country. Mental healthcare is publicly funded
and provided free of charge to all Emirati citizens. Despite that, mental health services in the
UAE are severely underutilized due to factors such as stigma, lack of awareness and lack of
cultural applicability of Western therapies to the local culture. Moreover, family therapy services
as well as services geared toward sexual minorities are nonexistent in the UAE. This doctoral
project aimed to identify barriers to delivering and accessing mental health and family therapy
services in the UAE from the perceptive of mental health professionals.

I
Table of Contents
Dedication ....................................................................................................................................... ii
Acknowledgments.......................................................................................................................... iv
Abstract ............................................................................................................................................v
Chapter I: Introduction .....................................................................................................................1
Statement of the Problem and Significance of the Study ............................................................2
Purpose Statement .......................................................................................................................3
Statement of the Researcher ........................................................................................................3
Definitions of Terms ....................................................................................................................5
Chapter II: Literature Review ..........................................................................................................7
The Country..................................................................................................................................6
Social Changes That Contributed to the Prevalence of Mental Health Illnesses .........................8
Socio-Economic Changes .........................................................................................................9
Family and Social Structure ......................................................................................................12
Role of Quran in the Arab Family System ................................................................................14
Family Unit .............................................................................................................................14
The Status of Mental Health in The UAE .................................................................................22
History of Psychology in the UAE .........................................................................................28
Emirates Psychological Association.......................................................................................31
Mental Health Research in The UAE .....................................................................................32
Prevalence of Mental Health Disorders in the UAE ..................................................................32
How Arab Cultures and Islamic Faith Shape Symptoms .......................................................38
Barriers to Mental Health Access and Delivery in the UAE ......................................................40
Stigma .....................................................................................................................................40
Cultural and Religious Values ................................................................................................41
Social Inquisitiveness .............................................................................................................43
Lack of Legislation .................................................................................................................44
Lack of Cultural Applicability................................................................................................44
Summary and Conclusion ..........................................................................................................45
Chapter III: Research Methodology...............................................................................................46
Research Design and Rationale ..................................................................................................47
BARRIERS TO DELIVERY AND ACCESS II
Population, Sampling and Sample Size......................................................................................48

Inclusion Criteria ....................................................................................................................49
Exclusion Criteria ...................................................................................................................49
Recruitment and Data Collection ...............................................................................................50
Instrumentation...........................................................................................................................51
Validity of the Instrument ......................................................................................................52
Data Analysis..........................................................................................................................54
Chapter IV: Results ........................................................................................................................55
Response Rate and Participants Demographics .........................................................................55
Data Management and Scale Reliability ....................................................................................57
Research Questions ....................................................................................................................59
Clinical Barriers to Family Therapy ..................................................................................59
Role of Culture, Religion and Stigma in the Delivery of Mental Health Services in the
UAE ...................................................................................................................................61
Non-Clinical Barriers to Mental Health .............................................................................65
Mental Health Barriers to Population with Sensitive Issues ..............................................68
Open-Ended Questions ...............................................................................................................71
Cross Tabulation ........................................................................................................................72
Chapter V: Discussions ..................................................................................................................73
Clinical and Research Implications ............................................................................................85
Limitations of the Study .............................................................................................................89
References ......................................................................................................................................90
Appendixes ..................................................................................................................................102
Appendix A ..............................................................................................................................102
Appendix B ..............................................................................................................................103
BARRIERS TO DELIVERY AND ACCESS III
Table Of Tables
Table 1: Demographic Information of the Participants .................................................................56
Table 2: Descriptive Statistics of the First Subscale .....................................................................60
Table 3: Descriptive Statistics of the Second Subscale .................................................................63
Table 4: Descriptive Statistics of the Third Subscale ....................................................................66
Table 5: Descriptive Statistics of the Fourth Subscale ..................................................................70
Table 6: Chi-Square Value Comparisons Between Emirati and Non-Emirati Participants...........72
Table 7: Chi-Square Value Comparisons Between FEMALE and Male Participants...................72
1
CHAPTER I
Introduction
According to World Health organization (WHO) mental health is a state of complete
physical, mental, and social well-being in which the individual realizes his or her own abilities,
can cope with the normal stressors of life, can work productively and fruitfully, and is able to
make contribution to his or her community (WHO, 2007). It requires balance in all aspect of
life.
One in four people in the world will be affected by mental or neurological disorders at
some point in their lives. Around 450 million people currently suffer from such conditions.
Further, the number of people living with depression has increased 18% from 2005 to 2015,
placing depression as the leading cause of disability worldwide. According to WHO, by the year
2020, mental health illness will be one of the leading causes of death and disability worldwide.
Only around one fifth of people with mental disorders receive a proper mental health diagnosis,
and less than 20% of those follow up with their treatment. Stigma, discrimination, and lack of
resources prevent proper treatment to mental health disorders.
The UAE has gone through unprecedented changes in the last 4 decades. The commercial
exploitation of oil allowed the UAE to transform from poverty to affluence. While the oil
revenues have significantly improved the quality of living by providing better access to health
care, education and employment, the rapidity of these changes may have also contributed to an
increase prevalence of mental health issues. While there is a lack of empirical studies to firmly
conclude on this matter, there are several cross-sectional studies that indicate high prevalence of
mental health disorders, especially mood disorders, mainly depression and anxiety. References to
BARRIERS TO DELIVERY AND ACCESS 2
psychological problem as a result of the perceived tension between traditionalism and modernity
is common in the literature in this geographical region. In reference to the tension of transition,
Ghubash, Daradkeh, Al-Muzafari, Manssori, and Abou-Saleh (2001) suggest, “the tension
between material advancement and social instability inevitably has consequences for the
psychological wellbeing of the inhabitants of developing nations” (p. 565).
Several empirical studies conducted in the UAE on the prevalence of mental health
disorders among both clinical and the general population based on the criteria of 10th revision of
International Classification of Diseases (ICD-10) for mental health disorders indicated similar
findings to those reported in many cultures in terms of the reported mental and psychological
disorders. UAE respondents were found to report a wide range of mental disorders such as
depressive disorders, anxiety disorders, somatization disorders, and alcohol and substance abuse.
For example, one study indicated that 1 in every 5 individuals suffer from anxiety and mood
disorder (Chudhary, 2016a). Another study showed that 17.5% percent of 1289 surveyed
teenagers (age of 13-20) have shown symptoms of depression (Chudhary, 2016b).
Statement of the Problem and Significance of the Study
Studies show that despite availability of mental health services, many individuals avoid
accessing and receiving mental health and family therapy services out of fear of stigma (Heath,
Vogel, & Al-Darmaki, 2016), some Emiratis deliberately avoid public health care system and
travel out of the country to receive mental health services (Al-Darmaki & Sayed, 2009). Many
individuals seek alternative yet less effective services such as traditional healers, to avoid stigma
(Thomas, Al-Qarni, & Furber, 2015). Identifying barriers to delivering and accessing existing
mental health and family therapy services will help mental health professionals to break and
challenge these barriers and eventually provide better mental health services.
Mental health research has been especially difficult to conduct in the UAE. As stigma is a
powerful barrier to proper access of mental health services in Middle Eastern countries,
individuals are not usually open to participating in mental health related research. The fear of
being outed or exposed prevent individuals from participating in empirical studies. As a result,
there is a lack of solid research backing for the need of effective mental health services in the
UAE. This research gap along with a lack of awareness and a collective stigma towards mental
health influences the lack of readiness of the country to face mental health challenges. Therefore,
mental health facilities and community centers are scant in the UAE. These point out to the need
and significance of the current study that aims to broaden the information available about mental
health services in the UAE and the effectiveness of its dissemination. The study aimed to
understand the barriers experienced in delivering and accessing mental health and family therapy
services in the country and its utilization.
Purpose Statement
The purpose of this descriptive survey study was to explore the barriers to delivering and
accessing mental health and family therapy services from the perspective of mental health
professionals currently working in diverse settings such as, the hospitals, mental health
community centers and universities in the United Arab Emirates.
Statement of the Researcher
My first exposure to psychology and social sciences was in high school, specifically in
my 11th and 12th grade. These classes were notoriously unpopular among students, however I
instantly gravitated toward them and found them to be interesting and fascinating. After I
graduated from high school, I was determined to pursue my undergraduate studies in psychology
and enroll in a psychology-related major.

I faced some difficulties in my journey to pursue my psychology degree. In the UAE and
generally in the Middle East, psychology was, and to a certain degree still is not only an
unpopular major but is also a stigmatized major to be enrolled in. Psychology major students and
people pursuing education in psychology in general are commonly perceived as having a
‘complex’ or being socially awkward and are often called ‘crazy’. Also, the lack of job
opportunities for psychology-degree holders contribute to its unpopularity. All these factors were
brought into discussion once I shared with my family that I would like to pursue a degree in
psychology. Even though I had the freedom to make the ultimate decision, I was influenced
enough to question what I thought was a passion of mine, especially when my older sister
pointed out that the United Arab Emirates, and specifically Dubai is becoming an important
business and financial hub in the world and it makes more sense to major in something related to
that. I eventually caved in and listened to their opinion, and I enrolled in a Business
Administration major. It only took me a few weeks to realize that I was in the wrong major. I
immediately changed my major to psychology, and I graduated in 2006.
After I earned my bachelor degree in 2006, I was hired in a public psychiatric hospital in
Abu Dhabi. As soon as I started working, I realized that the hospital, which is one of the biggest
in the Middle East had more services than the public used. I realized that there were barriers that
stood in the way of citizens taking advantage of the services available. On reviewing the
literature, I found that research exists that attempts to identify barriers to mental health from the
public’s perspective. However, there has not been any research conducted about the perceived
barriers from the perspective of mental health professionals in the UAE. I believe that identifying
gaps and barriers from the perspective of mental health professionals across the UAE will help
improve the delivery and the accessibility of services, and will hopefully give policy makers the
knowledge needed to make informed mental health policies
Definition of Terms
United Arab Emirates (UAE): UAE is a monarchy located in the Arabian Peninsula with a
population of about 9.2 million. In this study, the researcher will be using the word Emirati and
Arab interchangeably.
Mental health clinicians: A person who has at least earned a bachelor degree and works in a
professional setting where they provide academic, counseling, or psychiatric-nursing services
regardless of their certification or licensure status, because licensure is not a prerequisite for
practicing within a mental health discipline.
Barriers to accessing mental health: Difficulties that stand in the patients’ way to receiving or
accessing professional mental health services.

CHAPTER II
Literature Review
In this chapter, the researcher presents a description of the United Arab Emirates and the
significant economic and social transitions that happened in the country upon the exploration of
oil. The chapter also discusses how these changes contributed to the prevalence of mental health
disorders. The review of the literature also describes the family structure and dynamics of the
Emirati family and factors related to the family structure that lead to mental health-related issues
(Abudabbeh, 2005). Current status of the mental health field in the UAE, research gap and lack
of professional regulations will also be described as well as the existence of severe shortage of
mental health facilities. Trends and themes in the prevalence of mental health symptoms will
also identified (Salem, Saleh, Yousef & Sabri, 2009). Finally, there will be a discussion of
barriers that prevents individuals from accessing and receiving mental health treatment in the
UAE.
The Country
The United Arab Emirates (UAE), a monarchy federation of seven Emirates, was
founded by his highness Sheikh Zayed Bin Sultan Al-Nahyan in 1971, who was then the ruler of
the emirate of Abu Dhabi. The seven emirates are Abu Dhabi, the permanent capital of the
Union, Dubai, Sharjah, Ajman, Um Al-Quwain, Ras Al-Khaimah, and Fujairah. Before the
unification, every emirate constituted its own separate state, and all of them were colonized by
the United Kingdom. Sheikh Zayed, alongside with his highness Sheikh Rashid Bin Saeed Al-
Maktoom, who was then the ruler of Dubai, successfully united the seven Emirates into one
unified political entity. They also entered into a negotiation with the United Kingdom to end the
British colonization to the Emirates. In 1971, both the unification of the emirates and the ending
of the colonization marked the birth of a new independent country known as the United Arab
Emirates (Kjeilen, 2013).
The country lies in the Middle East and occupies a strategic location along the southern
part to the Strait of Hormuz, a vital transit point for the world’s crude oil. On its western borders
lies Qatar and the kingdom of Saudi Arabia, and on the east the sultanate of Oman. The country
has extensive shores on the Arabian/Persian Gulf to the North and the Arabian Sea and Indian
Ocean to the east. UAE has a total area of 83,600 square kilometers, 52,000 square miles, an area
comparable to the state of Maine. Most parts of the land is a dry desert. The country borders to
the west and southwest onto the “Empty Quarter”, which is one of the most hostile deserts in the
world. The coastal, heavily populated areas, have some of the most attractive beaches, many of
which are unspoiled and stretch for hundreds of miles. The population according to the 2011
census was 9,300,000 with 85% living in urban areas. The native population is less than
1,000,000. The rest are mostly of Asian origin with a significant number, roughly 46% from the
Indian subcontinent (about a million people are from the southern Indian State of Kerala).
Slightly more than 600,000 of the residents are of European and North American descent (United
Arab Emirates, National Bureau of Statistics 2011).
Before the unification, the independent or the un-united emirates were improvised,
sparsely populated, and severely underdeveloped. There was no running water, plumbing or
electricity. There was a severe lack of modern hospital and schools. People had to travel to other
countries, such as Egypt, Iraq, Kuwait or India to obtain modern education and health care
(Jabbour & Yamout, 2012). Before the 1970s, when oil was discovered, the Emirates’ economy
was dependent on fishing and natural pearl industry. After oil was discovered, the country started
its modernization. The UAE experienced rapid and unprecedented economical changes that
transformed the country in so many levels. Within two decades, the UAE has successfully
transformed from a poverty-stricken nation to one of the wealthiest countries in the world, with
modern health care and education systems as well as a developed infrastructure. In a recent
report, the UAE was ranked 4th in terms of best infrastructure in the world, ahead of countries
such the USA, France, and the United Kingdom (World Economic Forum, 2017). The quality of
life has also drastically changed; the current GDP per-capita is in par with that of Western
Europe and North American countries. In the last decade and a half, the UAE has been
constantly ranked amongst the top 10 in the world in terms of GDP per-capita. The annual
Human Development Index report (HDI), which is issued by the United Nations and is used to
rank countries based on their human, social and economic development performance has ranked
the UAE into a “Very High” human development category, similar to that of developed
countries, such as France, New Zealand and the United States. The other categories are “High”
“Medium” and “Low” (United Nations Development Program, 2003). In their annual report,
Amnesty International ranked the UAE as one of the world’s least corrupt countries (Amnesty
International, 2016)
Social Changes That Contributed to the Prevalence of Mental Illnesses
The UAE has the highest percentage of expatriate workers in the world (Hamza, 2016).
According to the National Bureau of Statistics for the United Arab Emirates (2011), only about
11% of the population are local Emiratis, whereas the rest are expatriates. The country has
provided an appealing business atmosphere to recruit millions of workers and investors from
other countries to help sustain and even further the country’s staggering economic growth
(Davidson, 2008). With its tax-free policy, business-friendly regulations as well as the country’s
political stability and safety, the United Arab Emirates has very successfully promoted itself as a
safe haven for business startups as well as the preferred headquarters in the Middle East for
many multinational companies. The UAE society has shown liberal attitudes towards welcoming
millions of workers and their families from different countries (Davidson, 2008), mainly from
the Indian Subcontinent countries, and the Philippines. A substantial percentage of workers are
from other Arab countries, such as Egypt, Lebanon, Palestine, Syria Morocco and many more
(Hamza, 2015). In the last two decades, the country has been receiving individuals from western
countries, such as United Kingdom, Germany, Russia, France, Australia, and the United States
(Davidson, 2008). Beside Arab expatriates, most guest workers are not Muslim, though they are
free to practice any religion. The country has been putting immense efforts in emphasizing
religious tolerance. For example, in the public-school system, funded by the federal Minister of
Education, curriculums teach students the values of tolerance and respecting different religions.
Further, the country has completely funded building many places of worship for non-Muslims
across the country.
Socio-economic changes .The welcoming attitude has encouraged many expatriates to
come to the UAE. Today, expatriates make up about 89% of the UAE population. This caused a
huge shift in the demographics of the UAE (the National Bureau of Statistics for the United Arab
Emirates 2011). In the UAE media, this phenomenon is referred to as “The Demographical
Crisis” (Demography, Migration, and the Labour Market in the UAE 2015). Many influential
local figures and academics argue that this has alienated the local population and pushed them to
be a small minority in their own country. It is a crisis that has been heavily discussed in the
media and is considered one of the touchy topics in the UAE. In contrast, despite being a
minority in their own country, Emiratis have considerably more power and privileges not
available to other nationalities. For instance, the overwhelming majority of decision makers and
legislatures in the country are local Emiratis. Further, the Emirati citizens enjoy many privileges
that expatriates do not, such as free health care, free education, free housing, and priority to
employment (Al-Darmaki & Sayed, 2009; Al-Darmaki & Yaqeeib, 2015).
Alongside the economic changes, social changes were bound to happen. The UAE was
transformed from a relatively closed and a traditional society, to being the Middle East’s biggest
melting pot (Peck, 2004). People from over 200 nationalities and multiple religious backgrounds
live in harmony and peace, in a region of the world where diversity has often led to conflicts, and
sometimes civil wars. With different languages, cultures, and religions co-existing and
interacting with one another, it was only inevitable that the UAE society was going to be
influenced and impacted by these cultures (Al-Darmaki & Sayed, 2009). Because these changes
happened within a very short period of time, new issues have arisen in the mental health field in
the country. The UAE society is now torn between the social traditions of the past and the
modernity of the present. These sudden cultural, social and demographic transformations has
forced the society to experience some changes in a pace, many argue the society was not ready to
catch up to (Lambart, 2008; Thomas, et al., 2015).
Many individuals in the UAE, especially the older conservative generation, has
experienced distress and felt threatened that their identity is being replaced by the influx of all
cultures that exist in the UAE, especially given that local Emiratis now make up only 11 percent
of the total population. They often find it difficult to maintain and pass down their values to their
children (Green & Smith, 2007). Schvaneveldt, Kerpelman, & Schvaneveldt (2005) believe that
this has created a generational gap between Emirati individuals who were born before the oil
discovery and the younger generations. The younger generations, unlike their parents, were
raised and brought up in a very diverse and multi-cultural society. They are constantly exposed
to different cultures, religions, and backgrounds. Many of these different cultures and
backgrounds seem less strict and more modern and appealing to them than their own. Therefore,
they are torn between preserving the traditional values that have been very strongly instilled and
passed down to them by their families, and adopting the new modern values from other cultures
that they are constantly exposed to, not only through media and the internet, but also through
first-hand social interaction with individuals from different cultures who live in the UAE
(Schvaneveldt et al., 2005).
In addition, role conflict was also cited as a result of the sudden multiculturalism the
country was exposed to (Lambert, 2008). Some Women are no longer expected to stay at home.
Many of them are college-level educated and are career oriented, which weakens the stereotyped
gender roles. As women started to pursue education and career, traditional gender roles became
unbalanced, and dual-income households became the norm. Further, many Emiratis feel that the
expatriates are taking away jobs, especially that expatriates are cheaper to hire than locals. Many
companies and corporations prefer to hire expatriates over locals, which led to higher rates of
unemployment among locals (Hamdan, 2009).
The need for psychotherapy increased due to problems experienced by the natives in
adjusting to these changes, as well as the need to find treatment methods that are less
stigmatizing than psychiatry and psychotropic medications (Al-Darmaki, 2014). Psychiatry has a
longer history than psychotherapy in the Arab World, including the UAE (Okasha, 1999). When
the UAE was first established in 1971, psychiatry and psychotropic medications were the only
form of treatment in mental health field (Kraya, 2002). Even though it was the only option,
psychiatry was stigmatized because it contains psychotropic medications. Culturally, individuals
who are prescribed psychotropic medications were looked down upon and are perceived in the
public eye as “crazy”. On the other hand, psychology and psychotherapy were introduced in the
country during the late 1970s (Kraya, 2002). It is looked at as a less stigmatized form of mental
health because it is only a talk-based therapy. It does not require a visit to a psychiatrist, nor does
it include medication.
The changes that came with modernization touched every aspect of people’s lives
(Brinson & Al-amri, 2006). Social changes usually do not catch up with the same speed of
economic advancements, causing social instability that potentially affect the well-being of
individuals in developing societies (Alexander, 2000). For example, in the UAE, the pace of life
tends to be slower which, in an isomorphic way, brings a slower pace of social change. The fast
changes and the economical advancements that happened in the country forced people to a much
faster pace of life, a pace they are not yet used to conforming to. This has changed the normal
way of life as locals attempt to adopt to an increasingly fast-paced cities, such as Dubai and Abu
Dhabi where the economy is becoming more competitive and global.
Family and Social Structure
The cultural, social, and religious characteristics of modern Arabs are a direct result of
some historical events that shaped their personalities and the way they interact with one another,
and the rest of the world. In the early 7th century, the area known today as the Arabian Peninsula,
witnessed the advent and the spread of Islam.
Prophet Mohammed invited the different tribes in the Arabian Peninsula, who were
involved in bloody wars with one another to unify under the will of Allah and his new religion
by the name of Islam (Bobrick, 2012). After unifying the tribes and converting them to Islam,
Mohammed and his army conquered surrounding territories of the Arabian Peninsula, such as
Yemen, Syria and Iraq. Shortly after that, Mohammed’s army invaded neighboring territories
such as Egypt and Persia. By the end of the century, the Muslim territory, known as the
caliphate, extended from central Asia to parts of western and southern Europe such as Spain,
Portugal, and France. This era witnessed the spread of the Arabic language to all the newly
conquered territories (Bobrick, 2012).
The golden age of the Arab civilization started toward the end of the eighth century until
the Mongols invaded Baghdad in 1258. Baghdad, the center of the Abbasid caliphate, was one of
the most advanced cities in the world, and an unrivaled center for education and research
(Bobrick, 2012). Students from all over the world came together to study at Bayt Al-Hikmah or
House of Wisdom. House of wisdom had the biggest collections of books from all over the
world. It was an intellectual center that was unmatched for the study of humanities, astronomy,
mathematics, medicine, and chemistry. Scholars from all over the world, such as Persia, Greece
and Europe came to study and made remarkable contribution in so many fields (Bobrick, 2012).
Beside Muslims, scholars affiliated to the Christian and the Jewish faith were also allowed to
study at the house of wisdom. With the support of the caliphate, scholars translated many books
from foreign languages such as Greek, Hindi, and Persian to Arabic. The center was destroyed
upon the Mongol siege and invasion of Baghdad. Historian reported that the books in the House
of Wisdom and other libraries in Baghdad were thrown into the Tigris river in huge quantities
that the color of the river changed to black because of the ink from the books. The Mongol
invasion also marked the end of the Abbasid caliphate (Bobrick, 2012).
The fall of Baghdad paved the way for the Ottomans to dominate and rule the Arab
World from the 13th to the 19th century. After that, in the late 19th and early 20th century, the
Europeans, mainly France and the United Kingdom, divided the Arab territories into colonies.
After the second World War, the Arab countries started gaining independent and form the
modern Arab countries known today (Bobrick, 2012).
Role of Quran in the Arab family system. The Quran is the holy book for Muslims.
Muslims believe that Quran is the direct word of Allah conveyed through his prophet
Mohammed (Barakat, 2007). Before the advent of Islam, the tribe was the source of strength.
Pre-Islam Arabs were expected to show blind loyalty and unquestionable devotion to the tribe as
it was considered the central unit of the society. After the advent of Islam, Mohammed
emphasized on the Islamic Ummah, which goes beyond the tribe. Ummah is the literal Arabic
translation for the word nation (Abudebbeh, 2005). In the Islamic context, the word ummah has a
strong religious overtone, which implies brotherhood between Muslims, beyond race and
language. The expressions Islamic ummah, or the Arab ummah are widely utilized to indicate the
similarities, shared histories and struggles between the Arab and/or Muslim nations.
Within the concept of ummah, the extended family is the most important social unit.
Rights and duties are specifically distributed to family members. Husbands are to protect,
provide and head the family unit. They have specific responsibilities toward their wives, son,
daughters, and parents. Wives on the other hand, have many responsibilities as well. As per
Islamic guidelines, they are instructed to obey their husbands and respect them as the head of the
family unit (Abudebbeh, 2007). The husband and the wife have responsibilities to support and
maintain the family in accordance to religious and cultural expectations. Family code of conduct
and honor is upheld to a high standard. The husband and the wife should always strive to
maintain or enhance the family status in public.
Family Unit. Traditionally, Arab families are patriarchal, authoritarian, and group-
oriented (Crabtree, 2007). The father is the head of the household. He has the final say on family
matters, and his authority is undisputed. Traditional old Arab houses are built to accommodate
the extended family, such as the father’s parents, as well as his married sons and their wives and
kids. As privacy is important and is considered part of the family honor, all Arab houses are built
surrounded by a wall to ensure privacy.
The father has full authority in the household. Everyone in the household, including his
wife, as well as kids and grandkids are expected to submit to his will. Family members usually
do not question his decisions openly. In addition to his roles in providing, protecting, and
supporting the family, the patriarch’s responsibly is to unify and solve any conflicts that might
arise within the household. Religious scriptures strongly command the wife and the kids to obey
the father. The father’s parenting style is typically authoritarian. He is expected to be the strict
disciplinarian in the family. The father’s authority and presence in the household is considered
essential to the cohesiveness of the family unit.
A study conducted by the United Nations Office on Drug and Crime and Crime
Prevention (UNODCCP, 2001) indicated that paternal absence in the Arab family, much more so
than maternal absence, was overrepresented as a factor leading to substance abuse. The results
showed that the loss of paternal figure was a significant theme in individuals with substance
abuse problems. The study emphasized the paternal and hierarchal nature of the Arab family
structure, with the father being the head of the household. When the father figure is absent, the
family homeostasis is vulnerable to instability.
The mother is usually the permissive parent. She is less strict and her authority is more
subtle and indirect. Her authority depends greatly on her relationship with her husband (Barakat,
2007). The more respect the father shows toward his wife, the more respect she receives from the
kids. Her authority also depends on the relationship she has built over time with her siblings,
sons and daughters. When conflicts arise between the father and the children, the mother
mediates between them, and adheres to her expected role as a peace keeper. It is socially and
religiously frowned upon for women to openly disagree with their husbands. When
disagreements or conflicts happen, the wife usually triangulates her kids, siblings, in-laws, or
parents to convey her views to her husband (Barakat, 2007).
In the last few decades, Arab women have gained more rights and have become more
vocal and outspoken about issues related to women rights and gender equality (Golley, 2004).
However, despite the strides Arab women have accomplished, the Western feminist perception
of Arab women did not change, rather, it continued to perpetuate the notion that Arab societies
are completely patriarchal and that Arab women are powerless and completely submissive to
their husbands, or male guardians. While some of that might hold truth, a lot of is biased by
superior western ideologies that are influenced by colonialist views, misinterpretation and
selectivism (Daneshpour,2017). For example, the literature in the west fails to identify that due
to high levels of education among women and government initiatives that aim to empower
women and fill the gender gap, many Emirati women enjoy better sense of self-agency and have
gained implicit power in their marriages (Hamdan, 2009). One study found that due to financial
independence, highly educated Emirati women are now more likely to divorce their spouses,
especially the less educated spouses than women in the past. (Al Gharaibe, Bromfield, 2012).
This shows that women in some sections of the society have gained a sense of agency and can
make decisions pertinent to their lives that used to be a taboo a few decades ago. Forster,
Ebrahim & Ibrahim (2014) believe that the last two decades have witnessed what they call a
“quiet revolution”. Emirati women have gained more legal rights and have economic power
more than any country in the Arabian peninsula.

Arab women are particularly affectionate and intimate with their kids. While the kids’
relationship with their father is hierarchal and formal, their relationship with the mother is less
formal and more casual. Arab mothers are especially close to their sons. The birth of a boy
marks a celebratory event in the family (Abudabbeh, 2005). In the past, a midwife usually
releases ceremonial chants and praises Allah if the baby was a boy. If the baby was a girl, the
midwife would not say anything. The preference of boys over girls in the Arab culture stems
from traditional views which state that boys can contribute to the family fortune by working
hand to hand with their fathers. Boys are also preferred because traditional views state they can
protect, maintain, and increase the family offspring by passing down the family name to the next
generation.
Arab men typically show much affection, respect, and devotion to their mothers. When
married, Arab men command their wives to respect and show full obedience to their mother-in-
law. Discord between daughters-in-law and mothers-in-law is a frequent source of contention in
the family, which brings a tremendous amount of pressure on the son. When this happens, the
son has to be diplomatic, and attempt to strike a balance between paying respect to his mother,
while also protecting his own honor by defending his wife (Abudabbeh, 2005).
The mother develops a special bond with her daughter. The mother-daughter relationship
is of a paramount importance to the mother and the entire family (Schvaneveldt et al., 2005). The
mother sees herself in her daughter. She takes prides in teaching her daughter how to become a
good wife and potentially a mother. When the daughter gets married and moves to live with her
husband and his family, her skills in running and maintaining a household are viewed as a
reflection of her parents and their adherence to social morals. As daughters grow older, they
become their mothers’ confidants and secret keepers. After the daughter is married, their
relationship evolves to a woman-to-woman friendship.
The relationship between siblings within Arab families is also hierarchal and gender-
based (Abudabbeh, 2005). Parents typically show more affection toward their daughters,
however, boys have more socializing opportunities and are free to interact with peers. Girls are
subject to more social restrictions as they are never allowed to leave the family house unless they
are accompanied by their parents or older brothers. Boys learn from an early age that they are
superior to their sisters, and that they can do or say things that are forbidden for their sisters
(Hamdan, 2009). They learn from an early age that their role is to protect and support their
sisters. If a sister behaves in an inappropriate way, her brothers are expected to take an
authoritarian role. Their disapproval of their sisters’ behavior is as powerful as that of a father or
a husband. Upon the father’s death, the oldest son in the family inherits the authority and become
the new patriarch. He assumes responsibility and authority over his mother and his unmarried
siblings.
The social structure of the Arab family emphasizes the cohesiveness of the group, where
collective good takes precedence over individual interest (Lambert, 2008). Individuals are born
in extended families, where they learn from an early age that maintaining harmony between
group members is more important than achieving personal goals. Individuals learn that they do
their expected share to maintain the cohesiveness of the group.
Naser & Al-Qutob (2004) discussed the concept of “Mosayara”, which is an Arabic term
that means “the effort of an individual to get along or to put up with”. They describe Mosayara
as being central to the formality of Arab family structure. In the social context of Arab societies,
this term refers to the effort a person makes to conceal, hide, or even deny personal thoughts,
opinions, or needs in efforts to maintain the homeostasis of the family system. A person in a
critical need of psychological help might deny himself access to professional mental health only
to save face, and maintain the honor of the family by avoiding brining embarrassment to the
members of the group.
The concept of honor in Arab and Emirati families include values such as chastity,
honesty, righteousness, hard work, educational achievement, and economic success. Individuals’
behaviors are reflections of their families’ reputations and their adherence to social norms. Good
deeds of a family member such as good moral reputations or having educational achievements
reflect positively on the family status (Al-Darmaki, Thomas & Yaaqeib, 2016).
Due to westernization and financial capability, nuclear family system, rather than
extended family system is the norm in the Emirati society today. However, the collectivist social
structure is still strongly evident in the family system. Families maintain the concept of extended
families. Ahl, which is the Arabic word for kin, is considered the extension of the nuclear family
system (Abudabbeh, 2005). Social expectations dictate that families have strong responsibilities
toward their kin. Families show their loyalty to their kin by engaging them in private family
matters such as child-rearing, marriages, and inheritance. In times of crisis, families turn to their
kin for social or financial support. Much socializing occurs between the extended family
members. Families consider their own kin as being the closest to them and the most worthy of
their time and respect (Abudabbeh, 2005).
It is typical in an Arab family for kids to socialize mostly with their grandparents, aunts,
uncles, and their cousins. Historically, although not as common nowadays, many families still
prefer marrying among relatives. These marriages serve to strengthen ties between members of
the extended family. From a western perspective, these family ties may seem extremely
enmeshed with problematic boundaries. In Arab cultures, such family ties reflect love, intimacy
and are viewed as normal. Arabs do not strive for greater autonomy or independence away from
the group.
Many important decisions, including the decision to seek professional mental health
services are taken after consulting the extended family. In most cases, family members show up
with the identified patient to demonstrate support and interest in the patient’s well-being. Even
though the country has witnessed modernization, the interdependency within the family unit still
outweighs individuality and the concept of personal privacy Eapen & Ghubas (2004).
In Arab cultures, taking care of the mentally-ill is the responsibility of the family, not the
society at large, nor the psychiatry hospitals. Admitting the mentally ill to a psychiatry unit
comes only after the family is no longer able to provide the appropriate type of care (El-Islam,
2008) . It is viewed as a right and a responsibility on the part of the family to take care of their ill
members. Beyond providing care, it is common that family members, and sometimes extended
family members, to contribute in paying the medical expenses for their sick loved ones.
Dependence on family members is expected in the Arab cultures, and it goes beyond childhood
and adolescence. Family members are expected to provide care to their adults as well, whether in
sickness or in health.
In exploring the role extended family members play on the psychological well-being of
patients, (El-Islam, 2008) noticed that schizophrenic patients who come from extended families
usually show better progress when compared to those from nuclear families. In extended
families, immediate family members do not have to deal with the burden of “keeping the secret”
of having a mentally ill member from the rest of the family. As it is no longer a secret, it
becomes easier to devote the effort in providing care and to become involved in the treatment
process. Further, the more family members involved, the easier it becomes to divide the care
between family members, which in return, reflects positively on the well-being and the stability
of the patients. Sulaiman, Moussa & El-Islam (1989) noticed that unlike common trends
elsewhere with schizophrenic patients, severe social withdrawal is not a common theme among
schizophrenic patients who come from extended family systems. Further, (El-Islam, 2008) in a
study that compared the prognosis of patients with psychotic symptoms, it was found that
patients who come from a single-parent household were more likely to have their treatment
interrupted, when compared to those from extended family systems. Another study conducted in
Kuwait, followed up survivors of suicide attempts, indicated that while the attempts itself
brought a certain degree of shame and disgrace to the family, the researchers noticed that patients
who showed steady progress were those who came from traditional family systems (nuclear and
extended), where the father is the authoritarian figure and the mother embodied the permissive
role (Okasha, Saad, Khalil, Sief El-Dawla & Yehia, 1994). The researchers noticed that those
who still had persistent suicidal ideations came from either divorced or unstable families.
Arab Families tend to attribute events and occurrences to external sources, such as
family or tribal decisions, government, social leaders, religious leader, or God (Al-Krenawi,
2002). As a consequence of such mentality, Arabs are brought up and raised with a less sense of
individuality and ownership from an early age. Instead, life events are attributed to an external
locus of control (Al-Darmaki, 2014). Therefore, it is very common that a personal sense of
responsibility is viewed in relation to his or her family or the extended community. For example,
it is common and acceptable for the family to be blamed if their child, even an adult child,
engaged in problematic behavior such as stealing. In such cases, the entire family takes the
blame and will carry the guilt and shame.

The Status of Mental Health in the UAE
The healthcare system is managed by the Federal Ministry of Health in the UAE (Al-
Darmaki & Yaaqeib, 2015). The Ministry of Health is the official body that legislates and
organizes healthcare regulations on a federal level. Abu Dhabi, Dubai, and Sharjah run their own
local healthcare departments and regulate their respective emirates. These local departments
usually run healthcare facilities that are built and funded by the local governments of each
Emirate. The local healthcare departments are independent from the Ministry of Health, however
they work in collaboration with the Ministry of Health (Al-Darmaki & Yaaqeib, 2015).
According to the World Health Organization (WHO, 2011) there is no independent
mental health policy in the UAE. Rather, there is a mental health care act as a part of the general
health care policy. The current mental health act came into effect in 1981. It was published in the
country’s official language, Arabic. The act has a vague definition of “Mental Health”. It
discussed the authorities’ right to detain patients who are actively psychotic. There was an
emphasis on forensic issues. Nothing was mentioned about patients’ right to consent. Patients’
are deemed enable to consent for themselves, regardless of the degree of cognitive impairment.
There was a paragraph that briefly talked about providing best possible care, and protecting
client’s dignity and humanity (Alhassani & Osman, 2015). In the last decade, there has been a
call for an updated mental health care act at the national level that protects the rights of the
patients (Badawi, 2012; Bell, 2014; Khalaf, 2016). Therefore, a new, more expansive mental
health law is currently in the making. Local newspapers discussed how the law will expand to
include greater rights and protections for patients and mental health workers (Kalaf, 2016). In
2014 the new mental health plan was discussed in the National Federal Council, the country’s
main legislative branch (Khalaf, 2016). The new plan emphasized on broader accessibility of
mental health care services in public hospitals, by designating psychiatry units or departments in
every major public and private hospital. However, mental health services are still a rarity in
primary mental health centers in small towns. The new policy also calls for integrating mental
health care services into primary health care centers and allocating resources to smaller
community mental health care facilities.
According to the World Health Origination (WHO), there are three specialized mental
health facilities in the UAE. There are around 500 beds in specialized psychiatric hospitals. An
average of 25 beds are reserved for psychiatric patients in general hospitals. There are 0.3
psychiatrists, 0.51 psychologists, and 0.25 social workers for every 100,000 inhabitants (WHO,
2011). The Ministry of Health estimates that there are around 33,000 mental health professionals
in total in the UAE. These figures indicate a severe shortage of mental health professionals and
mental health facilities as well. Reports indicate that in some cases, patients wait up to two
months for a vacancy in a mental health facility (Abed, 2014).
Abu Dhabi has the most extensive psychiatric services in the country followed by the
emirate of Dubai. In Abu Dhabi, the Behavioral Sciences Pavilion (BSP) is the main psychiatric
hospital (Kraya, 2002). It is a public psychiatric hospital that provides services to the entire
emirate of Abu Dhabi, which has a population of around 2.8 million. The hospital was built in
1994, and has 163 bed capacity. Besides the extensive inpatient and outpatient services, the
hospital provides day care services, wraparound services, psychometric evaluation and testing.
The hospital also has a forensic unit as well as a chemical dependency unit. Beside treating
common mental illnesses, the hospital also has a psycho-neurology unit, a geriatric unit, a child
mental health department, bariatric evaluation unit, and a court mandated department. The
hospital includes several departments, such as psychiatry department, psychology department,

social work department, occupational therapy department, community mental health department,
and day center department.
Another public mental health facility in Abu Dhabi is the National Rehabilitation Center
(NRC). NRC is a public rehabilitation center that provides both inpatient and outpatient
services. The NRC is a 12-step program with a 78-bed capacity. The Center provides individual
therapy, group therapy, and occupational therapy. The NRC has launched several initiatives to
educate the community on alcohol and drug abuse related issues. The Center also provides
educational courses for other mental health professionals across the country (Rasheed, 2017).
The center has recently opened a female adult unit, which did not exist before, due to the
strong stigma surrounding alcohol and drug abuse in women (Rasheed, 2017). Religiously,
alcohol and drug abuse are highly stigmatized in Muslim cultures, more so than any other mental
disorders, because consuming alcohol, or any substance that inhibits the brain function is viewed
as one of the greatest sins in Islam (Hamdi et., al, 2013). Alcohol usage usually bring shame to
the family name and reputation. It can also severely harm any marriage prospects within the
family. For these reasons, alcohol and drug abuse among women was rare in comparison to men.
(Rasheed, 2017) However, within the last decade, the number of women with substance abuse
related issues in the Arab world has increased (Loffredo et., al, 2015).
In Al-Ain, the second biggest city in the Emirate of Abu Dhabi, with a little over half a
million inhabitants, psychiatric services are provided through the psychiatry departments in the
city’s two major public hospitals. Al-Ain hospital has a psychiatry department with a 16-bed
capacity. Tawam hospital, the biggest hospital in Al-Ain with 461 non-psychiatry bed capacity,
only provides outpatients psychiatric services (Kraya, 2002).

In Dubai, psychiatry services are provided through Al Amal hospital and Rashid
Hospital. Al Amal, which translates to “hope” in Arabic, is a common name for psychiatric
hospitals in the Arabic speaking countries. Al Amal hospital is a specialized psychiatric hospital,
with a 276-bed capacity. In November 2016, the hospital relocated to its new facility. Besides
inpatient services, the hospital also provides outpatients services, psychiatric emergency
services, pediatric and adolescent services. The hospital also has a detoxication unit, a geriatric
unit, and a forensic unit. The hospital also provides outreach services for patients who do not
have the means to come to the hospital. Rashid hospital is a public hospital in Dubai that
provides only outpatient psychiatric services. In the other Emirates, most public hospitals
provide outpatient psychiatric services. Patients who need to be hospitalized due to mental
illnesses, are admitted in general hospitals (Al Mualla, 2011).
Sharjah Private Rehabilitation Center is a rehabilitation unit that is run by Sharjah Police
Department. The main mission is to provide rehabilitation services for individuals who have
been charged and indicted with drug-related charges. Under the federal law, usage of narcotics is
punishable by 4 years in prison. The Sharjah Police Department refers individuals to the center
for a 6-month mandatory rehabilitation course, who would otherwise be imprisoned for 4 years
under the federal law.
The private psychiatry sector is well established, especially in major cities, such as
Dubai, Abu Dhabi, Sharjah and Al-Ain (Kraya, 2002). Tens of psychiatric clinics and mental
health facilities exist in all major cities. Within the last decade, several psychiatric and mental
health clinics and centers have opened, especially in Dubai and Abu Dhabi. The services
provided cover a whole range of psychiatric services, such as child mental health, neuro-
psychology, autism centers, and psychological testing. There is a notable shortage in resources
and facilities in some areas such as domestic violence, eating disorders, and play therapy.
In general, public mental health services in the UAE primarily focus on severe and acute
symptoms that require hospitalization such as psychosis, active suicidal ideation, or substance
abuse-related disorders. Further, therapy services almost only exist as post-discharge or follow
up services for patients who have been previously hospitalized in psychiatric units.
There exists a severe shortage in public community mental health centers that provide
psychotherapy, or counseling services for everyday life problems, such as school or work-related
issues. Also, specialized community centers that caters to issues such as battered spouses, sexual
orientation issues, or gender identity are not available in the country. There is also a severe
shortage of clinicians in the community mental health centers that provide couples and family
therapy services. Therefore, family therapy services, as they exist in the US, are almost
nonexistent in the UAE. Rather, family therapy services are an extension or an adjunct to
individual therapy (R. AlShihabi, personal communication, March, 2016). There are a few
American and Canadian Marriage and Family Therapists in the UAE. Their clinical work is
mainly individual, and due to language barrier, their work is mainly geared toward expatriates
from western countries. Services rendered by clinical psychologists come closest to the type of
systemic therapy provided in the United States by Couple and Family Therapists (R. AlShihabi,
personal communication, March, 2016). In the UAE, symptoms are often treated from a medical
perspective by mainly psychiatrists or clinical psychologists. While many mental health
professionals believe that familial and systemic relationships play a significant role in the
development of psychological symptoms, systemic therapy modalities are foreign to most
mental health professionals. Mental health professionals are trained from a medical perspective
and they often adhere to it when diagnosing or delivering psychotherapy, which is often focused
on the individual. Clinicians’ strict adherence to the medical model and their lack of knowledge
and training of family therapy might serve as a barrier to delivering family therapy services
(Sayed, 2002). In addition, many clinicians in the UAE are often unaware of Marriage and
Family Therapy as in independent discipline. They also lack knowledge of Family Therapy
modalities. Sayed (2002), noticed that Arabic psychology and psychiatry is stagnant and is rarely
welcoming to new disciplines in psychology. He believes that Arabic psychiatry and psychology
is strongly influenced by and rather protective of the western medical model with its notions of
health and sickness, which might not suit Arab societies. Therefore, clinicians’ attitudes and
beliefs about Family Therapy as a new and an independent discipline might not be all that
positive after all.
Typically, family members are invited to participate in individual therapy when there are
issues related to the identified patient. Family members only participate in a session or a few
sessions as a part of the ongoing individual therapy and they perform roles to either support the
patients and/or to make sure that the patients are compliant to the treatment regimen prescribed
by the psychiatrists. Therefore, the family system is not looked at as a system where
psychological problems may have originated and be maintained. Basic family therapy concepts
such as family structure, communicating style, boundaries and hierarchy are not discussed from a
systemic perspective. Interaction between family members is not viewed as a primary reason for
psychological symptoms, therefore, systemic treatments are not offered.
While the recent universal wave of acceptance of sexual minority in western countries
have increased global awareness about LGBT rights (Wight, 2017), issues related to sexual
minorities are rarely addressed by mental health professionals in the UAE due to cultural and
religious reasons. Some mental health professionals in the UAE, especially those who were
trained in Western countries have shown positive attitudes toward sexual minority patients and
started providing affirmative therapy. However, LGBT Individuals are still largely marginalized
and often pushed to “change” (Al-Qasimi, 2011). Further, psychological aspects related to sexual
identity development and gender reassignments are not available, neither are resources or
facilities that provide mental health services for this population.
Homosexuality is condemned on cultural, religious, and even legal levels in the UAE. Until
this day, there is only one peer reviewed article regarding sexual minorities in the UAE (Al-
Qasimi, 2011). This shows how the topic is highly stigmatized even for mental health
professionals to discuss the topic. Alshihabi (2016) reported that many individuals in the UAE
travel out of the country to receive support and LGBT-related mental health services (S.
Alfardan, personal communication, October, 2017).
History of psychology in the UAE. Mental health services were established shortly after
the country gained its independence in the early 70’s. Mental health services only included
outpatient and inpatient psychiatry services. It was heavily based on psychotropic medication
(Al-Darmaki, 2009). Most psychiatrists were Arab expatriates, mainly from Egypt, Jordan, and
other Arab countries. An undergraduate psychology program was created in the country’s
official university, the United Arab Emirates University (UAEU) which was a milestone in the
development of the psychology field in the country (Al-Darmaki & Yaaqeib, 2015). In the early
1980’s, psychological and counselling services were introduced as adjacent supportive services
for people who are receiving psychiatry services. Toward the mid 1980’s, public hospitals started
hiring more psychologists, counselors, and social workers. Public hospitals then started to create
independent psychology departments (Al-Darmaki & Sayed, 2009). Towards the late 1980’s and
early 1990’s, several mental health facilities were built and started to offer freestanding services.
The need for solid and independent psychological services grew out of the rapid and
unprecedented social and economical changes that happened over the past three decades. The
country population doubled about 15 times from the early 1970’s to the early 2000’s, and the
indigenous people were abruptly exposed to massive influx of different cultures and backgrounds
which inevitably influenced the local culture. This exposure led to changes in deeply long held
beliefs, values and role expectations, which in turn, may have effected psychological wellbeing.
The government has put efforts into advocating and promoting mental health awareness,
whether through the generous spending on the public healthcare and mental healthcare systems
or extensive cross-country awareness campaigns (Alhassani & Osman, 2015). However, the
shortage of competent and culturally sensitive mental health professionals hindered these efforts.
Further, the pathology-based medical model that seems to reinforce stigma, as well as the public
tendency to resort to religious or traditional healers seem to add on to the underuse of the mental
health services. In addition, the public trust in the mental health system has been affected by the
noticeable malpractice cases and stories of unprofessional conduct that have been circulating and
were discussed publicly in local newspapers (Al-Darmaki & Yaaqeib, 2015). The lack of
licensing boards, as well as the lack of ethical practice guidelines have contributed to the
increase of malpractice incidents.
Despite the strides the discipline of psychology has made in the UAE, the practice of
psychology is still loosely regulated. The lack of regulations has negatively influenced the public
trust in the mental health services (Al-Darmaki, 2009). It has also enabled many fraudulent
mental health workers to exploit patients and find legal loopholes to perpetuate their
unprofessional and unethical practices (Bell, 2014). Many mental health clinicians, mainly
psychologists, as well as academics have expressed their concerns (Alshihabi, 2014; Badawi,
2012; Bell, 2014; Bill & Rizvi, 2014).
According to Al-Darmaki & Yaaqeib (2015), mental health professionals from different
emirates are working together to create a unified ethical code and licensure process for the
practice of psychology across the UAE. There have been ongoing efforts to create a federal
regulatory body that govern mental health professions in the UAE, but many challenges stand in
the way. For instance, the UAE is a federation, therefore, healthcare regulations, funding, and
licensing requirements vary from one emirate to another depending on the local licensing bodies
in every emirate. In addition, legislative efforts in the UAE seem to be directed at psychiatry and
psychology, with little or no consideration to other mental health professions such as family
therapy, or school psychology (Al-Maseeh, 2013). Presently, different emirates have different
requirements, for example, in Abu Dhabi, the Health Authority Abu Dhabi (HAAD) is the
licensing body for mental health clinicians. A master’s degree in any discipline of psychology is
required for applicants to be considered for licensing (AlShihabi, 2011). Applicants then undergo
an interview with two senior clinical psychologists who pass or fail applicants based on their
general knowledge of basic legal and ethical codes of the practice of psychology. Clinicians from
other countries, or those who obtained their degrees from outside the UAE, must be licensed in
their own country of origin before they can apply for licensure in Abu Dhabi (AlShihabi, 2011).
In Dubai, the Community Development Authority (CDA) is responsible for licensing.
CDA provides relatively clear and more strict guidelines. CDA provide licenses to social
workers, social counselors, and psychologist. Their licensing requirements vary depending on
whether the applicant is an Emirati or an expatriate. For expatriates, a master’s degree in any
discipline of psychology is required. If the diploma was from a university out of the UAE, it
must be accredited from the Ministry of Higher Education and Scientific Research. A minimum
of two years of post-certification experience in the field. Finally, applicants must pass the
licensing exam, which consists of a written and an oral part.
Emirates psychology association. In an effort to develop a uniform practice of
psychology across the country, the Emirate Psychological Association (EPA) was established in
Dubai in 2003 (Kruse, 2011). EPA is the only professional association that is officially
recognized in the field of psychology and social science. The association’s mission is to build a
resilient society against mental health disorders through raising awareness about mental health
issues as well as offering expertise and advice related to psychology. EPA also advocates for
greater public access to mental health services. The EPA also serves to bridge the existing gap
between mental health in the public sector and the private sectors by conducting meetings,
seminars, and forum to discuss current mental health issues to better serve the community
(Kruse, 2011).
Education in psychology is very limited. There are no doctoral level programs in
psychology or social sciences (Al-Darmaki & Yaaqeib, 2015). The well-established flagship
university of the UAE, the United Arab Emirates University (UAEU) has started offering a
master’s degree in clinical psychology in 2011. Only two federal universities offer a bachelor
degree in psychology, the UAEU (Since 1970s) and Zayed University (ZU) which only recently
started offering a bachelor degree in psychology. A few private universities started offering
bachelor degree in psychology, such as New York University Abu Dhabi, American University
in Sharjah and Middlesex university in Dubai. Training for psychologists in the UAE is
challenging. The number of mental health facilities that provide proper training and internship
opportunities for students is limited. Bilingual resources (in Arabic and English) are very limited,
and most of the resources are culturally irrelevant as these resources are borrowed from the
West. In addition, there is a lack of culturally competent supervisors to works with the diverse
population of the country (Al-Darmaki & Yaaqeib, 2015).
Mental health research in UAE. Mental health research is considerably neglected not
only in the UAE (Al-Darmaki & Yaaqeib, 2015). This is a phenomenon in the entire region, not
only the UAE. Osman & Afifi (2010) reviewed the research trends in the UAE and the
neighboring countries. They investigated all the published research in the UAE and the other
Arabian Gulf countries (Saudi Arabia, Bahrain, Qatar, Kuwait and Oman). They found that only
1 to 2 percent of the total research published was related to mental health. The UAE was the
most prolific in the numbers of the study published. The authors noticed that there was a
complete absence on research about systemic psychology (Osman & Afifi, 2010). Al-Darmaki
and Yaaqieb (2015) noticed that usually researchers in the field are non-Emiratis. Therefore, they
may not be culturally aware of social issues that should be investigated and researched. They
pointed that many of these researchers are academics who are mainly motivated by promotions.
Thus, their research topics may not be directly related to current mental health issues in the
country. In addition, many of their research is published in foreign languages in international
journals, which limits their actual benefit to the community.
Prevalence of Mental Health Disorders in the UAE
Despite the minimal number of studies about the prevalence of mental health disorders in
the UAE, some studies have shown that they do exist (Abou-Saleh, Ghubash & Daradkeh, 2001;
Al-Shboul & Sabri, 2004; Eapen, Jakka & Abou-Saleh, 2003; Ghubash & El-Rufaie, 1997;
Lawton, & Schulte, 2012; Salem, Saleh, Yousef & Sabri, 2009). One study noted that most of the
studies have been conducted on non-clinical population, such as students or general population.
Further, the studies that targeted clinical population recruited participants from primary health
care centers, rather than mental health community centers or specialized mental health facilities
(Lawton & Schulte, 2012).
Comparing findings in clinical studies is hindered due to the lack of clinical studies in the UAE
and the Arab region in general (Lawton & Schulte, 2012).
A study in the city of Al-Ain, in the emirate of Abu Dhabi was conducted to screen for
the prevalence of mental health disorder among UAE citizens. Systematic sampling was used,
and the sample size was 1394 participants. The purpose of the study was to find out about the
prevalence of mental illnesses as well as examining the effect of socioeconomic and
demographic factors. The United Arab Emirates University funded the study.
Participants in the study were between the ages of 18 and 40. 51% of the participants were males
and 49% were female. All participants were local Emirati citizens. 50% had more than 9 years of
education, 16% had a bachelor degree or above. The participants were cross-sectionally surveyed
between September 1997 to December of 2000. The survey used in the study was the Arabic
version of Composite International Diagnostic Interview as well as the Arabic translated version
of the Socio-Cultural Change Questionnaire.
The study found that 8.2% of male participants have sought mental health services
before, while the rate was 18.5% in female participants. These findings are consistent with other
studies that found that women use mental health services in higher rates than men (Al-Krenawi,
Jackson & Segal 2002). The most common symptoms reported in the surveys were tension,
worry, headaches, insomnia, fatigue, difficulty concentrating and a general sense of unhappiness.
Further, psychiatric disorders prevalence was 11.4% among female participants and 5.1% among
male participants. This is also a strikingly significant gender difference. Substance and alcohol
abuse symptoms was almost only present in men, whereas anxiety and mood disorders were the
most common symptoms among women. According to the study, the most common mood and
anxiety disorders found were phobias, generalized anxiety disorder, panic disorders, somatoform
disorders, depressive disorders, dissociative disorders, and obsessive compulsive disorders. No
gender differences were found in participants with schizophrenic disorders.
The authors account the higher percentage of psychiatric illness among women to social,
cultural, and religious restrictions and obligations placed on women and not men. The authors
also account the higher rate of mood and anxiety disorders in women to hormonal change. One
explanation the authors presented in regards to the high percentage of alcohol and drug-related
disorders and the lower rate of mood disorder among men is that men may have self-medicated
to cope with mental health disorders, which also explains the higher percentage of substance
abuse-related symptoms in men, whereas women sought mental health services instead.
In regards to the socioeconomic and demographic factors, the study found that presence
of mental health illness was highly associated with dysfunctional family dynamics, exposure to
family violence, mental health family history and exposure to chronic life difficulties. The risk to
developing mental illnesses increased with being exposed to dysfunctional family dynamics,
being, young, female, and past family history of mental illness. Also, comorbidity was found to
play an important demographic factor. 47% of the participants were diagnosed with more than
one disorder. The study also found out that polygamy increased the risk of mental health
symptoms in women. This finding is consistent with other studies that showed polygamy can
serve as a source of great stress for Arab women (Daoud, Shoham-Vardi, Urquia & O'Campo,
2014) as well as a precursor to mental illness in women (Shepard, 2013). No significant
statistical association was found between family income and education and the prevalence of
mental illnesses in the sample. Polygamy is legal in the UAE. An adult man can marry up to 4
wives, not vice a versa. Polygamy used to be very common up until 3 decades ago. However, the
practice of polygamy is declining significantly as Emirati women are becoming more educated,
career-oriented and aware of their rights. Recent statistics show that in Dubai, only 2.2% of all
marriages are polygamous (Alnowais, 2015).
Another study was conducted to examine the correlation between unhealthy life styles,
specifically smoking, obesity and lack of physical activity with the prevalence of anxiety and
depression among local citizens in the Emirate of Abu Dhabi (Moselhy et al., 2011). The sample
consisted of 2000 households of the UAE local population. 13.9% of the participants in the
sample had current diagnosis of depression, and 18.7% had a diagnosis of anxiety. The study
found that there was a negative correlation between depression and physical activity. Depression
was found to be twice as high among participants who were sedentary. Women were
significantly less active than men. One explanation for this might be the social and cultural
restrictions among women that limit their mobility. Also, most fitness clubs in the country are
mixed gender, where men and women share the same space. Emirati women were raised to be
shy and cautious around men. Therefore, many of them would avoid subscribing in fitness clubs
because of social modesty, which may have contributed to the high levels of inactivity among
women.
The study also found that adults who showed symptoms of anxiety disorders were more
highly likely to be smokers or ex-smokers. The frequency of anxiety among smokers was 3 times
that of non-smokers. The study also found that there was a significant difference between male
smokers (21.2%) and female smokers (0.7%) in terms of frequency of anxiety symptoms.
Further, the study indicated that participants with anxiety and depression symptoms were more
likely to be obese. Participants with depression and anxiety were more likely than those without
these disorders to be obese (Moselhy et al., 2011).
A study conducted in the emirate of Sharjah, the third largest city in the country, was
conducted to estimate the prevalence of mental health distress among a sample of individuals
with type 2 diabetes (Sulaiman, Hamdan, Tamim, Mahmood & Young, 2010). The sample
consisted of 347 participants. 65.4% of the participants were females. The study was a cross-
sectional study, where participants were interviewed between January 2007 to June 2008. The
mean age of participants was 53, and around 84% of the participants were UAE citizens, while
the rest were from other Arab countries (Egypt, Lebanon, Syria, Palestine and Sudan). Kessler
Psychological Distress Scale (K6) was used as an instrument to screen for psychological distress
among participants. K6 is a self-administered psychological scale that screens for mood and
anxiety disorder. The study found that 12.5% of surveyed participants showed significant
symptoms of depression and anxiety. The study found that those who scored high on the K6
scale (more anxiety and depressive symptoms) had poorer control over their diabetic symptoms
and practiced practice unhealthy lifestyle habits, such as bad eating and low exercise. Further,
participants who scored high in depression, struggled with self-care, and had lower adherence to
their diabetic care regiments (Sulaiman, Hamdan, Tamim, Mahmood & Young , 2010).
Socio-demographic analysis showed no statistically significant gender difference in
regards to the prevalence of depression or anxiety among participants. The result however
showed that unmarried participants scored significantly higher rates of anxiety and depression
when compared to the married participants. This may have been due to the social, and familial
pressure placed on people to get married. In Arab cultures, the society looks down on adults who
have reached a certain age and stayed unmarried. The society perceives unmarried adults as
weak and irresponsible. They are subjected to continues harsh criticism and scrutiny from the
family and the society in general. It might have been specifically relevant to participants in this
study, since most participants were older (mean age 53) and are more likely to hold more
traditional views about marriage. The results also showed that non-Emirati participants reported
significantly more symptoms of anxiety and depressions when compared to Emirati participants.
One explanation might be that in the UAE, Emirati citizens are eligible to very generous
privileges from the government such as free healthcare, free housing and free education, as well
as priority employment. Expatriates, on the other hand, cannot be eligible to these privileges.
Expatriates usually are paid less than locals, and are less prioritized for employment. Further,
expatriates tend to live away from their families or extended families. All these reasons may
have contributed to the higher rates of anxiety and depression among non-Emiratis.
Another study conducted in Dubai to measure the prevalence of mental health care
indicated an elevated level of anxiety (Lawton & Schulte, 2012). The sample was 49
participants, who attended an outpatient health care community center in Dubai. 69% of the
participants were females, with a mean age of 36.8. Participants were of different nationalities:
39% European, 14% Middle Eastern (including local Emiratis), 12% North American and the
rest were from the Indian subcontinent, South East Asia, Africa, and Latin America. Participants
filled out self-administered surveys for anxiety, depression, self-esteem, PTSD and alcohol
consumption. 75.5% of participants met the clinical criteria for anxiety. Of these, 94.6% reported
mild to moderate symptoms, 5.4% reported severe symptoms of anxiety, 57.1% met the clinical
threshold of depression. In terms of co-morbidity, 51% of participants suffered from both
depression and anxiety (Lawton & Schulte, 2012).

The findings indicated that there was no correlation between the demographic variables
and mental health variables. However, the results indicated that individuals who were
unemployed suffer higher levels of anxiety and lower levels of self-esteem. PTSD was correlated
with high levels of depression and anxiety. PTSD levels were surprisingly high in the study, even
though the sample was not a specific trauma population. An explanation the author gives is that
many of the participants may have been born and lived their entire life in the UAE, but they
cannot be Emirati citizens because of the way the immigration system functions. Emirati
citizenship entails more than identifying a country of residence. Besides the elite treatment and
privileges it entails, such as considerably higher salaries, free education, free healthcare, etc., the
UAE citizenship also resembles a sense of true and official belonging to the country (Lawton &
Schulte, 2012).
How Arab cultures and Islamic faith shape symptoms. Cultures and religious
practices shape mental health symptoms (Hodge, 2016; Luna & MacMillan, 2015; Sternthal et.
al, 2012). For example, it is common in the Arab culture to believe that the devil or “Satan” can
tempt a person to commit or think wrongfully. A clinician who is not familiar with the culture
might categorize such belief as a symptom of mental illness.
Being thankful for whatever fate God has chosen for an individual is an integral part of
the Muslim culture. It is one of the 6 pillars of Islam. Therefore, it is considered blasphemous to
give up or to lose hope, as doing so is seen as losing faith in God. In the Muslim faith,
individuals are rewarded in the afterlife for all the suffering they had to endure. El-Islam (2008)
believed that religious beliefs may shape the symptomology of some mental illnesses, especially
the affective ones. He noticed that among a sample of clinically depressed patients from Kuwait,
helplessness was not as prominent of a symptom experienced by patients.

El-Islam (2008) also noticed that depression is described differently among patients from
the Gulf countries in comparison to their western counterparts. With more focus on the somatic
experience of depression, many patients describe depression as chest tightening or heartache that
is unbearably residing over the chest or the heart area. In the Arabic dialect of the gulf countries,
the expression theegat sadr, which literally translates to “chest tightness” is wildly used to
describe a low mood. A clinician who is not familiar with the culture of this region might
misinterpret it as somatization or focus entirely on a possible physical diagnosis.
In the Arab world, especially among older generations, women do not have many
responsibilities outside of their households. Their social interactions are limited to parents,
siblings, spouses, cousins and female friends. Therefore, disorders such as agoraphobia, which is
more common among females than males in most cultures, is not a very common disorder among
Arab women. Traditionally, Arab men have more responsibilities and social encounters and
social interactions than women. Therefore, such disorders are much higher among men. (El-
Islam, 2008)
Because of the outspread social oppression and the subservient roles women are
conditioned to take in such societies, dissociative disorders and conversion disorders are more
evident in women than men (El-Islam, 2008). Moreover, it is socially acceptable for women to
show physical symptoms or somatic disorders than to show direct signs of emotional distress. In
addition, physical symptoms are taken more seriously than emotional or mental symptoms.
Physical symptoms usually call for a physician intervention and are viewed as serious and
attention-worthy symptoms, whereas emotional symptoms are stigmatized and can be seen as a
reflection of a flawed character or lack of faith.

Barriers to Mental Health Access and Delivery in the UAE
Research has shown that there are numerous barriers to the provision of mental health in the
UAE. Some of these barriers are stigma (Dardas & Simmons, 2015; Heath et al., 2016; Nasser &
Al-Qutob, 2005) preference for traditional healers (Thomas et al., 2015) religious and cultural
beliefs (Al-Darmaki & Sayed, 2008; El-Islam, 2008), the public lack of trust in mental health
services (Al-Darmaki & Sayed, 2008; Lawton, & Schulte, 2012) and the lack of legislation as
well as ethical guidelines in the mental health field (Al-Darmki & Yaaqieb, 2015).
Stigma. Stigma is commonly reported as one of the biggest barriers to the delivery of
mental health services (Al-Darmaki, 2003; Al-Darmaki et al., 2016; Heath et al., 2016; Naser &
Al-Qutob, 2004). Mental illness is highly stigmatized in the Arab world. It is often looked at as a
character flaw and a punishment from God. Since the Arab structure is collectivist, it is common
for mental illness to be also viewed as a flaw in parenting, implying a deficit or a dysfunction not
only in the patient, but also in his family. Arab families take their reputation seriously, and a
mental health diagnosis can strongly harm a family’s reputation.
The length to which Arab families go to avoid seeking professional help for their sick
family members is what Naser & Al-Qutob (2004) refer to as heritable stigma. The impact of
heritable stigma extends beyond individuals, to include family members or the larger group of
the patient’s relative. Receiving a “shameful” mental health diagnosis, such depression, or
schizophrenia can have powerful consequences on the rest of the family. It can harm a single
woman’s prospect for marriage, or be used as a leverage by husbands to obtain a second wife.
The shame that comes with mental health diagnoses or symptoms can also be inherited and
passed down through generations.

The fear of heritable stigma can prevent individuals or families from receiving mental
health services, which in turn, prevents or delays the proper diagnosis and treatment. A study
was conducted in Jordan of 50 primary health care physicians measuring their knowledge about
mental health illnesses. The study shockingly found that it was a common practice among some
physicians to knowingly avoid giving a mental health diagnosis to their patients, even when their
patients met the clinical threshold for such diagnoses (Naser & Al-Qutob, 2004). Many
physicians in the study admitted that they willingly overlooked or tried to conceal their patients’
mental health symptoms because they did not want to harm their patients by giving them a
mental health diagnosis, as a mental health diagnosis can mean an end to their career and social
lives. These findings are very worrisome, especially when studies show that physicians are at the
first line of defense, as Arabs first turn to primary health care physicians when a family member
experiences mental health symptom (Dardas & Simmons, 2015).
Cultural and religious values. Arabs have a set of shared values and beliefs that shape
their views about mental health services. The literature has shown that Arab cultural practices
play a significant role in shaping their perceptions of mental disorders and attitudes toward
mental health services (Dardas & Simons 2015). Muslim Arabs are very religious, and they
strongly believe in superstitions. In the Arab culture, mental health is strongly associated with
superstitious beliefs about evil eye, spirits, and possessions, which they believe leads to madness
(Jnoon) (Al-Darmaki, 2014). Even though not in reference to or in direct relation to mental
health, many of these concepts are mentioned in Quran, which makes them indisputable and
believed by even those who are highly-educated. It is a common practice among Arabs to turn to
alternative, less stigmatizing ways of dealing with mental illnesses, such as going to traditional
healers or religious healers. A study conducted in Al-Ain city in the UAE found that 48% of
individuals who were admitted to an inpatient mental health unit have consulted a traditional
healer at some point before considering mental health services. In the UAE society, traditional
healers are a part of the culture, and have existed long before the advent of the modern mental
health services (Lawton, & Schulte, 2012). They are widely accepted by people from almost all
socio-economic and educational levels, as their practice is supported by religious beliefs.
Traditional healers are usually consulted on different issues such as psychological distress,
mental illness symptoms and private matters. They provide different types of non-psychological
as well as nonpharmacological interventions such as herbal remedies, reciting Quran over a sick
person to drive away the possessing spirits or the evil-eye (Thomas et al., 2015). The main
premise of traditional healers is that the etiology of individual symptoms or illnesses are often
external. Externalizing the source of illnesses is consistent with the way Arabs are brought up to
believe that life events happen because of external reasons, which provides relief from feelings
of personal responsibility, shame, and internalized stigma. Individuals usually self-report feeling
relieved and supported after visiting traditional healers (Thomas et al., 2015), however their
symptoms persist and often deteriorate (Dardas & Simmons, 2015). While these practices serve a
cultural and spiritual purposes, they do not, cure symptoms of mental illness. Patients continues
to suffer due to the lack of proper medical care provided.
Even though there are no indications in the Islamic religious literature that reciting
Quran on a sick person alleviates symptoms, many individuals still adhere to this practice.
Contrarily, scriptural Islamic teachings in both Quran and Hadith urge individuals to seek
treatment from proper resources when they get sick. However, the fear of being stigmatized by
seeking professional mental health services overpowers the desire to receive proper mental
health services (Dalky, 2012). Thomas et al., (2015) argued that while the concept of psychology
and psychotherapy is Western and is therefore viewed as alien and foreign to the Arab culture,
traditional healers are from within the local culture. They are usually well-versed in Islamic faith
as well as the local culture, which makes them more familiar and credible as a source of
treatment.
In the UAE society, people are encouraged to seek support from social support system
and traditional healers to avoid stigma. Traditional healers do not require sharing private
information, which in turn, increases their appeal. Even though mental health services and
professional counseling are viewed as important resources to deal with psychological problems,
it is not yet as widely accessible as in the Western world (Brinson & Al-amri, 2006).
Psychotherapy is still viewed as “just talk” that might not necessarily bring about the required
change. Furthermore, psychotherapy requires sharing private personal and family-related
information. In the UAE culture, talking to a stranger about a family issue is viewed as betrayal
to the family (Al-Darmaki, 2011)
Social inquisitiveness. Social inquisitiveness is also one of the barriers that stands in the
way of people getting the psychological services they need (Nasir & Al Qutob, 2015). In
collectivist cultures, the concept of personal space is very limited or even nonexistent. It is a
social norm in Arab cultures to be inquisitive and sometimes even intrusive about other family
members, neighbors, and coworkers’ lives. It is common for individuals to ask intrusive
questions if an individual expresses the desire to seek professional psychological help. To avoid
that, it is common for individuals seeking mental health services to leave their cities or villages
to get the services needed. Few people can afford to look for help outside of their cities. Nasir &
Al-Qutob (2015) suggested that some people who are unable to leave their cities to look for help,
prefer to suffer silently than to have their mental illnesses “exposed”. In the UAE, social
inquisitiveness, still is a barrier that can compromise accessing mental health services, though
not as apparent, as the country has become less collectivist due to rapid social changes.
Lack of legislations. Lack of trust in the mental health field has also been cited as a
barrier to the delivery of mental health services in the UAE (Al-Darmaki & Yaaqeib, 2015; Al
Mulla, 2011). Al-Darmaki & Yaaqeib (2015) suggested that the lack of governing laws and
ethical guidelines has harmed the field. They believe that the lack of ethical guidelines and the
vagueness of laws have led many mental health professionals, especially in the private sector to
exploit patients for their own personal and financial gains. They also believe that the lack of
culturally competent local Emirati mental health professionals who are familiar with the local
culture has contributed to the negative view the public have on mental health, as the alternatives
are either Arabs from different countries who are not fully aware of the local culture, or Western
professionals who are often unable to speak the language.
Lack of cultural applicability. Psychologists and their allied disciplines in the Arab world
have paid little attention to the cultural applicability of psychology to the Arab population (Sayed,
2002). This has current ramification on the discipline of psychology and mental health in general,
which led the public to view psychology and its practices as a western concept that is culturally
incompatible to the Arab culture. The current mental health systems in the Arab world have been
almost completely inherited from the Western understanding of what constitutes health and
sickness (Abi-Hashem, 2014). Therefore, it failed to conceptualize many local expressions or
culturally-specific rituals that are unbeknownst to the West and labeled them as deficient and
symptomatic, instead of exploring the cultural meaning attached to such expressions. The public
in the Arab world are not only suspicious, but often angry at a discipline of science that
symptomizes their very way of life, just because it does not align with the Western way of life.
Summary and Conclusion
The United Arab Emirates is a new country that was a British colony until 1971. When it
gained its independence in 1971, the UAE has transformed to modernity and the country has made
strides on many social and economic aspects. The resulting conflict between traditional values and
modernity has given rise to many familial and mental health problems and therefore increased the
need for mental health services in the UAE. Mental health services are scant in the country, and
the field of mental health is loosely regulated. Family therapy as we know in the westernized
nations is not available in the UAE. There is a shortage in the number of mental health facilities
and resources. Moreover, the number of trained mental health professionals is not enough to cover
the country’s needs. Further, despite the minimal number of research, it has been documented that
mental health illness are prevalent among the population of the UAE. Underutilization of mental
health services in the country has also been documented. Many barriers have contributed to the
underutilization of services. Finally, mental health resources and services to LGBT are almost
nonexistent in the country. LGBT individuals are marginalized and have no access to LGBT-
related mental health sources that meet their needs.

CHAPTER III
Research Methodology
In this chapter, the researcher will discuss the methodology and the research design used
to answer the research question. Research worldview, research design and rationale, Sampling,
recruitment and data collection, instrumentation as well as data analysis will also be discussed in
this chapter.
The research question for this study was “what are the barriers in delivering and accessing
mental health and family therapy services in the United Arab Emirates from the perspective of
mental health professionals”. The researcher adopted a Post-positivist worldview to conduct this
study. Post-positivist worldview allows the researcher to observe social phenomenon as they
exist “out there” separately from the researcher (Creswell, 2007). The goal of research in post-
positivism, is to discover a single reality, to create new knowledge through the application of
proper scientific methods by deductive methods, such as testing theories, specifying variable(s)
and group-comparison. Post-positivism adopts the idea that an absolute truth cannot be reach,
due to the lack of absolutes. In post-positivism, the researcher applies rigorous qualitive methods
and data analysis to “approximate” reality. The research should have a minimal interaction with
subjects, and his/her bias (views, perceptions, political views) should be controlled in order to
obtain scientifically sound results. (Creswell, 2007).
Post-positivism fits well with the current study, because the researcher was trying to
explore new knowledge that exists out there about mental health barriers in the United Arab
Emirates. The new knowledge was constructed by collecting data through survey methodology
using a survey instrument that was developed for this study.

Research Design and Rationale
This study used a quantitative methodology. More specifically, a cross-sectional
descriptive survey design was used to examine the perception of mental health professionals in
the UAE about the barriers that stands in the way of delivering and accessing mental health and
family therapy services to the public. This quantitative method was selected because it fits the
researcher’s purpose of explaining a phenomenon by collecting numerical data (Muijs, 2004).
Moreover, the researcher’s aim for the study was to get the opinion of a large number of mental
health professionals in the UAE about mental health barriers, and a quantitative descriptive
survey method was the most suitable way to achieve this goal. The purpose of this descriptive
research study was not to determine cause-effect or to discover causal relationships. Instead, it
was more exploratory to explain features (Kumar, 2011).
There are three different types of descriptive methods used in quantitative research,
observational methods, case-study methods, and survey methods (Hale, 2011). The method used
in this study was the survey method. The main reason for the researcher to use a survey approach
was the need to explore the opinion of mental health professionals about the barriers to
delivering and accessing mental health services, that could not be easily observed. Since the
researcher wants to obtain the opinion of a large number of mental health professionals in UAE,
a case study methods was not used.
In addition, this study was univariate, which means there is only one variable being
examined which is the mental health professionals’ perception about barriers to accessing and
delivering mental health services. In univariate studies, the variable is not manipulated or
changed to control an outcome. Rather, the main purpose is to describe, summarize and find
pattern in the data. The study is also cross-sectional, in that, data will be collected from the
participants at one time point and there will be no follow-up or longitudinal collection of data.
Population, Sampling and Sample Size
The population of interest in this research study consisted of mental health professionals
across the seven Emirates in the UAE. Researcher used purposive criterion and snowball
sampling techniques to recruit mental health professionals. Purposive sampling is a
nonprobability sampling approach, where the participants are selected based on their fit for the
study rather than random selection. Criterion sampling is a type of purposive sampling strategy
where the researcher recruits participants who best fit the inclusion criteria for this study.
Through purposive criterion sampling, the researcher was able to obtain a representative sample
that fitted best for the study in terms of the knowledge they have about the subject matter.
Purposive sampling methods may prove to be effective when limited participants can serve as a
primary source data due to the nature of the topic investigated or the study design (Creswell,
2007). This type of sampling strategy fits the current research because the researcher targeted
mental health professionals in the UAE, which is a small and limited population. Further, since
there is a shortage in the number of mental health facilities and establishments in the UAE, and
since most mental health professionals are concentrated within these few facilities, targeting
participants within these facilities has reflected a fairly representative sample of mental health
professionals in the UAE. In addition, snowball sampling technique was used in this study. In
snowball sampling technique, participants recruit future participants among their acquaintances.
Snowball sampling is often used in hidden populations that are difficult for the researcher to
access. The researcher used snowball sampling technique in smaller emirates and rural areas of
the country where mental health professionals are scarce.

Inclusion criteria. Participants were mental health professionals in the UAE, mainly
psychologists, psychiatrists, social workers, counselors, psychiatrist nurses, and psychology or
psychiatry professors across the UAE. Participants were practicing/working in mental health
facilities such as psychiatry hospitals, community mental health facilities, private practice clinics
and universities at the time they were recruited for the study. Participants must have had at least
an undergraduate degree in a mental health related field such as psychology, counseling, social
work, psychiatry, and nursing. Licensure status was not considered as a criterion for recruitment
as licensure is not a prerequisite in the UAE for a professional to practice mental health.
Exclusion criteria. Potential participants who are not fluent in reading and writing in
English were from the survey as the survey was in English. This did not bias the sample, since
fluency in English is a requirement for employment in the healthcare field in the UAE. Further,
mental health practitioners who were not practicing at the time of the study were excluded from
the study as the study was looking at current barriers that exist in delivering and accessing
mental health services in the UAE. Potential participants were not discriminated against based on
any other criteria such as age, gender, religion, nationality, urban/rural setting, sexuality or any
other demographic characteristics. Since the number of mental health professionals in the UAE is
limited, based on the researcher’s knowledge of the field, the researcher initially planned to
recruit as many participants as possible. The researcher estimated that the number of participants
to be anywhere between 80 to 120 participants. Based on the limited number of primary source
participants related to this study, this number is representative of the general population.
However, this plan changed after the researcher started data collection. Due to the severe
shortage of the number of mental health professionals in the UAE, which is well documented in
the literature, (Abed, 2014; Al-Darmaki & Yaaqeib, 2015; Salem, Saleh, Yousef & Sabri, 2009)
it was too hard for the researcher to collect data from the initial number of participants he
estimated. After spending a month and a half in the UAE collecting data, the researcher noticed
that the shortage is much more severe than the what is documented in the literature. After
consulting with Dr. Fatima Al-Darmaki, who is one of the most published researcher in the
mental health field in the UAE about the sample size, Dr. Al-Darmaki suggested that a sample
size between 35-45 would be appropriate as it would represent10-12% of the entire population of
practicing mental health professionals in the UAE.
The researcher proposed a sample size amendment to the dissertation committee and the
dissertation committee approved the proposal. The researcher was able to collect data from 53
participants which was the final number of participants of the current study.
Recruitment and Data Collection
The researcher went to hospitals, community mental health centers and universities to
collect the data from the targeted population. Researcher identified hospitals based on his
knowledge and previous experience as a mental health professional in the country. There are
only two well-known psychiatry hospitals in the emirates of Abu Dhabi and Dubai from where
the researcher will recruit participants. Further, the researcher went to the city of Al Ain as well
as the emirates of Sharjah and to recruit participants from psychiatry departments located in
general hospitals in these areas. In addition, the researcher also recruited workers from the two
public rehabilitation centers in the country, which are located in the emirates of Abu Dhabi, and
Sharjah. To recruit academics, researcher targeted participants from psychology departments in
the three existing universities in the country where there are psychology departments. These
universities are located in the emirates of Abu Dhabi, Sharjah as well as the city of Alain. The
researcher was not able to collect data from smaller emirates due to limitation of time and
resources.,
The researcher physically handed the surveys out to all clinicians in the selected agency.
The researcher informed the clinicians that participation is voluntary and that they can chose to
fill out or not fill out the survey and instructed them to return the surveys (both complete and
incomplete) to an envelope placed in a communal area in the agency.
Instrumentation
A demographic form (Appendix A) was given to all participants where questions
regarding the participants’ demographic characteristics such as, age, gender, nationality, religion,
language proficiencies, education and occupation will be asked.
The instrument used in this study was a survey developed by the researcher (Appendix B).
The survey was written in English. Use of English language was not a barrier to data collection
as fluency in English is a requirement for the employment of mental health professionals in the
UAE. Items in this survey were developed from the themes that emerged from the exhaustive
and in-depth review of the literature presented in this study. Further, the researcher has also
consulted a cultural expert of the Emirati culture, Dr. Rami Alshihabi. Dr. Alshihabi is a mental
health professional who earned his degree in Clinical Psychology from a west coast university in
the USA. Dr. Alshihabi has practiced mental health as a clinical psychologist both in the USA
(2004-2008) and in the UAE (2008-present). Dr. Alshihabi has expertise in quantitative research
and survey instruction. In addition, the researcher consulted an Emirati mental health researcher
and professor, Dr. Fatima Al-Darmaki. Dr. Al-Darmaki is one of the most renowned and
published researchers in the field of mental health in the UAE and the entire region. Dr. Al-
Darmaki has major publications (journals, textbook chapters and articles) both nationally and
internationally. Dr. Al-Darmaki has earned a Ph.D degree in counseling psychology in 1998
from a Midwestern university in the United States. Dr, Al-Darmaki helped with developing
question items that are applicable and appropriate to the local culture. In addition, since he is
fluent in both Arabic and English, Dr. Alshihabi helped with the readability and wording of the
question items.
Furthermore, the researcher conducted in-depth interviews/conversations with two mental
health professionals about the mental health situation in the country. This helped in the
development of the items in the survey to correctly represent the content area that the study
wanted to explore.
The final revised survey has a total of 50 Likert-scale questions in the survey. There are four
main sections in the survey, Clinical Barriers to Family Therapy, Role of culture, religion and
stigma, Non-clinical Barriers to Mental Health and Delivery and Accessibility of Services to
populations with sensitive issues. Each section has 10, 15 ,17 and 8 items respectively with an
open-ended section where participants can enter any additional comments for each section. The
Likert-scale items were rated on a five-point scale that will range from strongly agree to
Strongly disagree with an option for ‘Neither Agree Nor Disagree .
Validity of the instrument. Content validity refers to the degree to which a survey truly
measures what it is supposed to measure. In descriptive research, content validity consists of two
aspects, item validity and sampling validity. Item validity indicates to what degree the survey
items truly measure the intended content. Sampling validity however is concerned with how well
the survey items covered the total aspects of content area (Mertens, 2004).
To ensure content validity, the researcher has followed three criteria. First, the instrument
was developed based on the main themes found in a previous research the researcher has
conducted about the mental health field in the country. In this research, the researcher has
worked with a Marriage and Family therapy professor who has done extensive research about
mental health in collectivist cultures. Second, the instrument was reviewed by a panel of mental
health experts in the United Arab Emirates. The panel included an Emirati professor of
psychology in Abu Dhabi, who earned a PhD in counseling psychology in 1998 from a Midwest
university in the USA. The panel also included an Emirati clinical psychologist, who earned a
PhD in clinical psychology in 2009 from a university in the east coast in the United States. Both
panel experts are well-versed in the field and have published research about the mental health
field in the UAE. In addition, both of experts were born and raised in the UAE and are aware of
the nuances of the local cultural. Furthermore, the instrument was also reviewed by the chair of
this dissertation. Third, the researcher invited 3 potential participants to provide feedback and
give initial comments on the survey (e.g., length of the instrument, readability of the survey, the
length of the items). Based on the feedback the researcher received from the two mental health
experts and two participants, the survey was adjusted accordingly.
The feedback the researcher received was mainly about changing some wordings of the
question items so it becomes more readable and culturally applicable. Another feedback the
researcher received was about moving the questions that are related to mental health laws and
policies to the middle or the end of the survey instead of the beginning. Placing questions about
laws, policies at the very beginning of the survey might be threatening to participants, since
critiquing laws and policies in the UAE is not common, and might give a wrong impression
about the survey. Finally, the panel experts praised the idea of including a section about barriers
related to the LGBT community and stated that it was a positive step toward familiarizing mental
health professionals in the UAE with the community and issues related to it. However, they
notified the researcher that some participants may not be used to be asked about the topic since it
is considered a taboo in the culture. In addition, the 3 potential participants reported that they
were able to complete the survey without any issues.
In the pilot study with 3 participants, the researcher examined the Cronbach Alpha values
of the scales before proceeding to the actual study. The Cronbach alpha for the scale was .61.
Though the Cronbach Alpha was lower than the acceptable value, which is .65, it was acceptable
to proceed to the actual study for reasons further elaborated and explained in the results section.
Data Analysis
Statistical Package for Social Sciences (SPSS) software was used to analyze the
collected data. The researcher entered the data collected through both the demographic form and
the survey into the SPSS software to run a descriptive analysis. The researcher looked at
frequencies, percentages, means, modes, and standard deviations. The researcher used pie-charts,
bar charts as well as statistical graph charts to report the results. For the open-ended questions,
answers were coded for specific themes and then frequencies were calculated and reported.
CHAPTER IV
Results
This chapter reports the analysis of the data collected. The response rate, participants’
demographic information, instrument reliability, and responses to the research questions are
presented. Descriptive statistics, such as mean, median and standard deviation were used to
explore the perspective of mental health professionals about barriers to accessing and delivering
mental health and family therapy services in the UAE. Independent samples and t-tests were
used to explore differences between perspectives of Emirati and non-Emirati mental health
professionals as well as gender differences. In addition, data obtained for each subscale in the
survey was analyzed using descriptive statistics and reported separately.
Response Rate and Participant Demographics
The survey was handed out to 80 mental health professionals in total, of which only 53
completed the survey. Every participant received the survey in a paper format. Among the 53
participants who completed the survey, almost one third were females, and a little less than a two
third were males. Seventeen percent of participants had a Medical degree, 18.9% had a PhD
degree or an equivalent such as Psy.D. or M.D., 22.6% had Master’s degree, 34% had a
Bachelor’s degree, 5.7% had a diploma and 1.9% had other degrees. Sixty two percent of
participants were under the age of 45, whereas 35.9% were 45 years of age or older. Around 2%
of participants preferred not to disclose their age. Clinicians (psychologists, social workers,
counselors, and psychiatrists) formed around 40% percent of the sample size, whereas
academics, professors, and researchers were about 10%. Psychiatrist nurses were the largest
group of the study with around 24.5 percent. Out of the 53 participants, about 10 indicated that
they belonged to other related professions such as, lab technicians, nutritionists, clerics, and
receptionist at mental health facilities.
The demographic information of the participants is represented below in Table 1
Table 1: Demographic Information of the participants.
Frequency Percentage
Gender Female 30 56.6

Male 20 37.7
Missing 3 5.7
Diploma 3 5.7
Bachelor’s Degree 18 34
Education Level Master’s Degree 12 22.6
PhD/equivalent 10 18.9
Medical Degree 9 17
Other 1 1.9
18-24 1 1.9
Age 25-34 13 24.5
35-44 19 35.8
45-54 11 20.8
55+ 8 15.1
Prefer Not To Say 1 1.9
Psychologist 5 9.4
Social Worker 4 7.5
Counselor 2 3.8
Occupation
Academic/Professor 3 5.7
Psychiatrist 11 20.8
Researcher 2 3.8
Psychiatric Nurse 13 24.5
Other 10 18.9
Missing 3 5.7
Emirati 25 47.2
Nationality Other Arabs Expat 17 32.1
Non-Arab Expat 11 20.8
Muslim 48 90.6
Christian 2 3.8
Religion Catholic 1 1.9
Other 1 1.9
Missing 1 1.9
A little less than half were Emiratis (47.2%), whereas 32% of the participants were Arabs
from other countries, mainly Jordan, Palestine, Egypt and Syria. Non-Arab expatriates were
about 20.8% of the sample size. Ninety percent of the population identified as Muslim, whereas
6% identified as either Christians or Catholic. Less than 4 percent of the population identified
either as “other” or failed to answer the question.
Data Management and Scale Reliability

Out of the 53 surveys, there were 6 that had missing items. So only 47 surveys were fully
completed. The researcher used the mean substitution method to handle missing data. In mean
substitution method, the mean score of every participant in a specific subscale is used to estimate
the missing data. This allows the researcher to utilize the collected data in an incomplete dataset.
According to Tabachnick & Fidell (2012) mean substitution is a reasonable estimate for missing
variables in a data set that has a normal distribution. For the present study, SPSS analysis showed
that the data is normally distributed.
In addition, in the survey, some of the items were correlated in a reversed order to the
rest of the scale items. For example, item number 3, “Most mental health disorders occur due to
reasons such as patients’ temperament, chemical imbalance, or intrapersonal reasons, rather than
family-related factors”, was negatively correlated to the rest of the items in the scale. So, these
items were reversed scored (DeVellis, 1991). A total of 10 items in the survey were reverse
scored.
The Cronbach alpha for the entire survey was .841, which indicates that there is a high
internal consistency across the scale. However, the Cronbach Alpha value varied across every
subscale. The Cronbach Alpha value of the first subscale, Clinical Barriers to Family Therapy,
was .492. The Cronbach value of the second subscale, Role of Culture, Religion and Stigma was
.799. The Cronbach value of the third subscale, Non-clinical Barriers to Mental Health, was .603
and the Cronbach value of the fourth subscale, Delivery and Accessibility of Services to
Populations with Sensitive Issues, was.576. Even though most of the subscales had Cronbach
Alpha lower than the suggested value, literature states that the values are acceptable in many
cases. Serbetar & Sedlar (2016) suggests that in scales with items fewer than 10, the Cronbach
Alpha value can be quite small, which explains the high consistency value across the entire scale
and the relatively lower values across separate subscales. According to literature when the aim is
to measure or establish the existence of correlation between two variables, or when developing a
psychometric instrument, the Cronbach Alpha value has to be .70 or above. However, when a
scale measures different things and broad descriptive concepts such as in this study, it is very
well accepted to have a Cronbach Alpha value that is lower than .60 (Lance, Butts and Michaels,
2006). In many cases, the lower alpha value is a result of conceptual heterogeneity (the sale
measure different things) rather than a poor internal consistency (Lance et al., 2006). In addition,
culture factors may contribute to a lower Cronbach alpha. Spector (2015) suggests that when a
scale is developed in a certain culture or country and is administered in a dissimilar culture, this
might result in a reduced Cronbach Alpha value, especially if the scale was developed in a
different language than the mother language of participants, which is the case in this study.
Research Question
The central research question for this study was, “what are the barriers in delivering and
accessing mental health and family therapy services in the United Arab Emirates from the
perspective of mental health professionals?”. The research question was answered through the
four different subscales, each subscale discussing a specific set of barriers.
Clinical Barriers to Family Therapy. In the first subscale, Clinical Barriers to Family
Therapy, the highest score a participant can achieve is 50 points, which indicates that
participants’ beliefs about mental health and family therapy contribute to many clinical barriers
in practicing family therapy in the UAE. Conversely, the lowest possible score is 10, which
indicates that participants’ beliefs about mental health and family therapy contribute to little or
no clinical barriers to practicing family therapy in the UAE. The mean subscale score was 25.7
(SD = 3.60) which is below the midpoint of 30. This may mean that the participants’ beliefs
about mental health and family therapy may lend itself to low clinical barriers to practicing
family therapy in the UAE.
The researcher also looked at the mean value of every item in the sub-scale to identify
specific areas that contributed to clinical barriers. A score between 1 and 3 for each item
indicates that the stated item was not viewed as a barrier (indicated that the barrier is nonexistent
or less evident), and a mean greater than 3 indicated that the question item was viewed as a
barrier (indicated that the barrier is evident).

Table 2
Descriptive Statistics of The First Subscale, Clinical Barriers to Family Therapy
Item Mean SD
1. The type of relationship patients/clients have with their 1.24 .43
immediate family members play a strong role in their
psychological stability and wellbeing.
2. While creating treatment plans for patients/clients, it is important 1.56 .69

to engage family members and discuss their role in the problem
and their role in the resolution of the problem.
3. Most mental health disorders occur due to reasons such as 3.15 1.02
patients’ temperament, chemical imbalance, or intrapersonal
reasons, rather than family-related factors.
4. Treatment of mental health patients/clients is successful when 1.73 .78

family members are brought into therapy.
5. Family members are willing to participate in therapy sessions 2.79 1

with the identified patient/client.
6. I am trained in Family Therapy. 2.67 1.20
7. I often use Family Therapy as one of the treatment modalities in 2.62 1

my clinical work.
8. Family members often do not see themselves as contributing to 3.6 .92

the mental health problems of the identified patient/client.
9. It is easy to bring members of the family into the hospital or other 3.4 .94
mental health facility to be part of the therapy/treatment.
10. Families seek psychological therapy when they experience family 2.96 1.17
issues (e.g., domestic violence, parent-child problems, marital
conflicts, teenage problems etc.).
Looking at the mean score of the individual items, it seems like participants believe that
families play a major role in clients’ mental health wellbeing. They also seem to support the idea
of bringing in families into therapy and involving them in treatment planning. For instance,
100% of participants agreed or strongly agreed that the type of relationships a patient has with
her/his family member plays a strong role in their wellbeing. Ninety two percent of participants
agreed or strongly agreed that it is crucial to involve family members when creating treatment
plans for patients.
The review of the items also revealed several areas that could potentially serve as a
barrier to the practice of family therapy in the UAE. Around 40% of participants agreed or
strongly agreed that mental health disorders occur due to intrapersonal factors, such as chemical
imbalance or temperament rather than family-related factors. Only around 30% of participants
agreed that mental health disorders occur mainly due to family-related issues. In addition,75% of
participants agreed or strongly agreed that family members do not see themselves as contributing
to the development of mental health problems of the identified patients. Further, only 37%
agreed or strongly agreed that families seek psychological help when they experience family
issues
In regards to using family therapy as one of the treatment modality, around 57% agreed
or strongly agreed that they use Family Therapy as a treatment intervention and 53% of
participants stated that they are trained in Family therapy.
Role of Culture, Religion and Stigma in the Delivery of Mental Health Services in
the UAE. In the second subscale, Role of Culture, Religion and Stigma, the highest score a
participant can achieve is 65 points, which indicates that participants view religious, social and
cultural values as contributing to a little or no barriers to delivering mental health services in the
UAE. Conversely, the lowest possible score is 13, indicates that participants view religious,
social and cultural values as contributing to a lot of barriers to delivering and accessing mental
health services in the UAE. The mean subscale score was 34.4 (SD = 6.53), which is lower than
the median score of 45. This may mean that participants believe that culture and religion play a
role in creating barriers to the delivery of mental health services in the UAE.
The researcher also looked at the mean value of every item in the sub-scale to identify
indicates that the stated item was viewed as a barrier except for items 22 and 23.
A mean greater than 3 indicates that the item is not viewed as a barrier to the delivery of mental
health services in the UAE except for items 22 and 23. Items 22 and 23 discuss perceived needs
or importance, therefore the mean value for these items do not indicate an existence of a barrier
or lack thereof. For the same reason, the mean value for these items was not calculated in the
overall mean scale score.

Table 3
Descriptive Statistics of The Second Subscale, Role of Religion, Culture and Stigma
Items Mean SD
11. Mental illnesses are highly stigmatized in the Emirati culture. 2.35 1.07
12. Seeking psychological help for family problems is stigmatized in the 2.39 1.09
Emirati culture.
13. Stigma of seeking professional help is the main reason for 2.39 .96
underutilizing mental health services in the UAE.
14. People prefer seeking traditional methods of help (e.g., mutawas, 2.37 .94
religious healers, etc) for psychological problems.
15. People trust traditional healers more than mental health professionals in 2.67 .87
treating mental health problems.
16. Seeking help from mental health professionals is more stigmatizing 2.26 .94
than seeking help from traditional/religious healers.
17. people are often reluctant to seek mental health services because of 2.26 .86
their fear to bring shame to the family.
18. Approaching mental health issues from the medical model that 2.94 1.04
diagnosis and pathologizes, reinforces stigma.
19. People believe that seeking mental health services is a sign of 2.45 .88
weakness in the person.
20. People believe that seeking psychological help is indicative to the 2.81 1.07
person’s lack of faith in Allah (God).
21. The concepts of psychotherapy, psychiatry and family therapy are 2.84 .98
foreign to the local culture.
22. Knowledge of the Arabic language is important in providing mental 1.52 .69
health services. *
23. It is important for mental health professionals to be aware of cultural, 1.32 .54
social, and familial aspects of the Emirati culture. *
24. Clients and families in the UAE tend to trust mental health providers 2.33 .69
who are of the same culture or background.
25. Cultural, and religious background of the mental health provider is not 3 .54
a barrier to providing mental health services to Emirati patients/clients.
* Indicates that the mean for these items was not calculated in the overall mean score.
It seems that the majority of participants agreed that cultural, social and religious norms
are contributing to barriers in delivering and accessing mental health services in the UAE. For
instance, 88% of participants agreed or strongly agreed that mental illness is stigmatized in the
UAE. Similarly, around 66% of the population agreed or strongly agreed that seeking
psychological help for family problems is stigmatizing. A participant expressed: “…the stigma
associated with seeking help remains high”. Further, around 71% of participants agreed or
strongly agreed that people are afraid to bring shame to their families by seeking psychological
help. Around half of the participants (49.1%) agreed or strongly agreed that people believe that
seeking mental health services is indicative to a lack of faith in Allah. Around 28% answered,
“disagree” and 22% said that they “neither agree nor disagree” for this item.
It looks like participants also agreed that people prefer alternative methods of help to deal
with mental illness. For example, 60% agreed or strongly agreed that people tend to trust
traditional healers more than mental health professionals. In addition, 43% agreed or strongly
agreed that seeking help from traditional healers is less stigmatizing than seeking help from
mental health professionals. Only 19% disagreed, and around 37% answered neither agree nor
disagree for this item.
Further, 87% agreed or strongly agreed that clients and families in the UAE tend to trust
provider who are from the same cultural background. The response to item #25 seemed
contradictory to the response to item#24. That is, 38% of the participants seemed to believe that
the cultural background of the mental health provider is not a barrier when providing mental
health service to Emirati families, whereas 36% believed that it is a barrier. This was inconsistent
with participants’ answers to Item #24. This could be because item #25 was negatively worded,
which is typically considered a limitation in surveys.
The majority of participants believed that knowledge of cultural, social and linguistic
issues of the Emirati culture is important. Around 89% of participants agreed or strongly agreed
that knowledge of the Arabic language is important when providing mental health services in the
UAE. Similarly, 96% or strongly agreed that it is important for mental health provider to be
aware of the cultural and social aspects Emirati culture. A participant commented “mental health
providers should know the culture, religion and tradition of the UAE in order to provide best
services”. Another participants added “providers must have the knowledge of the culture and the
Arabic language”.
Non-clinical Barriers to Mental Health. In the third subscale, Non-Clinical Barriers to
Mental Health, the highest score a participant can achieve is 65 points, which indicates that
participants view nonclinical issues (e.g. administrative and logistic issues) as contributing to a
lot of barriers in the delivery and access of mental health in the UAE. The lowest possible score
is 13, which indicates that participants view nonclinical issues as contributing to little or no
barriers to the delivery and access of mental health services in the UAE. The mean subscale
score was 38.7 (SD = 4.85) which may indicate that the participants believe that non-clinical
issues contribute to creating barriers to the delivery of mental health services in the UAE.
The researcher also looked at the mean value of every item in the sub-scale in identify
indicates that the stated item was not viewed as a barrier except for items 35, 38, 39 and 42. A
mean greater than 3 indicated that the question item was viewed as a barrier, except for items 35,
38, 39 and 42. These items that talk about a need or importance of certain issues, and therefore
the mean values of these items have no correlation to barriers. For the same reason, the mean
value for these items was not calculated in the overall mean score.
Table 4
Descriptive Statistics of the Third Subscale, Non-clinical Barriers to Mental Health

Item Mean SD
26. The governmental funding for mental health services across the 2.71 1.16
UAE is adequate.
27. The shortage of qualified mental health professionals across the 3.30 1.13
UAE contributes to the lack of public confidence in the mental
health services.
28. The current number of mental health facilities is enough, and 3.67 .95
there is no need for more mental health facilities across the UAE.
29. Northern emirates and rural areas have adequate mental health 3.73 .85
services and facilities.
30. The travelling distance is one of the barriers to using mental 3.77 .89
health services in the northern emirates and rural areas of the
UAE.
31. People in northern emirates and rural areas would use mental 2.33 .83
health services more often if there were adequate services
available in their geographical location.
32. Lack of awareness about the availability of mental health services 3.67 .82
is one of the reasons for underutilization of mental health services
in UAE.
33. Adequate Information about mental health services and providers 2.92 .95
are made available to the public in the UAE.
34. Governmental strategies that aim to increase the public’s 2.69 1.04
awareness of the benefits of mental health services are in place.
35. Mental health strategies and campaigns are needed to increase the 1.81 .62
public accessibility to mental health services in the UAE. *
36. I am aware of an existing Mental Health Act in the UAE. 2.47 1.04
37. The existing Mental Health Act ensures the rights and 2.30 .86
responsibilities of patients and their families.
38. A new and independent mental health policy that is separate from 1.94 .86
the general health policy is needed. *
39. It is important that the rights of patients, (e.g. rights to consent) is 1.67 .72
protected in the new mental health policy. *
40. Individuals would trust mental health services and use it more 1.83 .76
often if there were clear mental health policies and regulations.
41. Patients with mental health issues in the UAE have less rights 2.60 1.08
compared to those in other countries.
42. A unified mental health licensure requirements and procedures 1.83 .72
across the UAE would improve the practice of mental health
services. *
*Indicates that the mean for these items was not calculated in the overall mean score.
Looking at the mean score of individual items, participants seemed to believe that non-
clinical issues contribute to creating barriers to delivering mental health services in the UAE.
For instance, the majority of participants seem to believe that mental health services in
geographical locations that are far from major cities are scarce. For instance, around 62% of
participants disagreed or strongly disagreed that northern emirates and rural areas have adequate
mental health services and 73% agreed or strongly agreed that the traveling distance for
individuals from northern emirates is a barrier to utilizing mental health services.
Participants seemed to believe that the mental health field in the UAE is in need for better
laws and regulations. Sixty three percent of participants agreed that they are aware of an existing
mental health plan. However, around 73% agreed or strongly agreed that there is a need for an
updated mental health plan that is separate from the general healthcare plan. A participant
commented “The mental health act issued in 1983 seems not only outdate, but is rather inactive”.
Around 48% believed that mental health patients in the UAE have more or less equal rights when
compared to patients in other countries, whereas 21% of participants believed that mental health
patients in the UAE have less rights compared to those in other countries. In addition, around
92% of participant agreed or strongly agreed that the right of patients to consent should be
protected in the new mental health policy. Finally, 89% agreed or strongly agreed that the public
would trust mental health services and use it more often if there were clearer policies and
regulation. Similarly, 88% agreed or strongly agreed that a unified mental health licensure
requirements across the UAE would improve the practice of mental health services in the UAE.
A participant expressed “I would suggest a revision to the licensure requirements for mental
health professionals as it is not unified across emirates and across nationalities”.
On the other hand, participants showed mixed views about few non-clinical barriers to
mental health. For example, 55% of participants agreed or strongly agreed that the current level
of government funding to mental health services is enough, and around 28% disagreed or
strongly disagreed. About 26% answered “neither agree nor disagree. More participants (45%)
than not (26%) agreed or strongly agreed that the government’s strategies to increase awareness
about mental health are in place, whereas 28% neither agreed nor disagreed. Similarly, 38%
agreed that adequate information about mental health services are made available to the public,
while 30% disagreed and 32% neither agreed nor disagreed. On the other hand, 64% of
participants said that the number of current mental health facilities is not enough. Moreover,
around 53% agreed or strongly agreed that the shortage of qualified mental health professionals
contribute to the public distrust in the mental health field, whereas 26% disagreed or strongly
disagreed and 21% neither agreed nor disagreed. Seventy three percent agreed or strongly agreed
that the lack of awareness about the availability of service is a major barrier to utilizing mental
health services.
Mental Health Barriers to Populations with Sensitive Issues. In the fourth subscale, Mental
Health Barrier to Populations with Sensitive Issues, the highest score a participant can achieve is
25 points, which indicates that participants acknowledged the existence of many barriers to
delivering mental health services to the LGBT population in the UAE. The lowest possible score
is 5, which indicates that participants acknowledged little or no barriers to delivering mental
health services to the LGBT population in the UAE. The mean subscale score was 18,86 (SD =
2.83).
The researcher also looked at the mean value of every item in the sub-scale in order to
identify specific areas that contributed to clinical barriers. A score between 1 and 3 for each item
indicates that the stated item was not viewed as a barrier, except for items 43, 45 and 46. A mean
greater than 3 indicated that the question item was viewed as a barrier, except for items 43, 45
and 46. Items 43, 45 and 46 discuss perceived needs or importance of certain issues, therefore
the mean values of these items do not reflect a barrier or a lack thereof. For the same reason, the
mean value for these items was not calculated in the overall mean score.
Table 5
Descriptive Statistics of The Fourth Subscale, Delivery and Accessibility of Services to
Populations with Sensitive Issues
Item Mean SD
43. There is a need to provide culturally sensitive training to 1.64 .59
practicing mental health professionals to be able to treat
challenging issues related to sexual and gender identity, and
Lesbian Gay Bisexual Transgender (LGBT)-related issues. *
44. Practicing mental health professionals in UAE are well trained 3.03 .96
to treat sensitive issues related to gender and sexual identity as
well as issues related to LGBT individuals.
45. There is a need to provide a safe environment for patients with 1.79 .68
sensitive issues (e.g., gender/sexual identity, LGBT
population, etc.) so that they can express issues related to
them. *
46. Issues related to gender/sexual identity, and LGBT population 1.95 .76
need to be addressed by mental health professionals in the
UAE. *
47. The current level of mental health services provided to patients 3.13 .94
with sensitive issues (e.g., gender/sexual identity, LGBT
population, etc.) is satisfactory.
48. Mental health professionals are comfortable in addressing 3.05 .86

sensitive issues (e.g., gender/sexual identity, LGBT-specific
issues, etc.).
49. Patients/clients with sensitive issues (e.g., gender/sexual 3.77 .89

identity, LGBT population, etc.) are usually reluctant to seek
psychological help because of fear of being rejected and/or of
possible legal consequences.
50. The lack of mental health services for individuals with 3.96 .83
sensitive issues (e.g. gender/sexual identity, LGBT population,
etc.) marginalizes them and increases the likelihood of mental
health stressors for this population.
*Indicates that the mean for these items was not calculated in the overall mean score
In this sub-scale, it seems that participants acknowledged a great need for providing
competent services to the LGBT population in the UAE. Ninety four percent of participants
agreed or strongly agreed that there is a need to provide training to mental health professionals to
be able to competently deal with patients with LGBT-related issues. Similarly, 85% agreed or
strongly agreed that there is a need to provide safe environment for LGBT patients/clients so
they can express issues related to them. In addition, around 88% of participant agreed or strongly
agreed that issues related to LGBT population in the UAE need to be addressed.
However, they also acknowledged that there are currently several barriers to providing
competent services to this population. Only 32% of the participants agreed or strongly agreed
that mental health professionals in the UAE are comfortable in addressing issues related to the
LGBT with their patients/clients. The majority of participants (43%) neither agreed nor
disagreed with this statement and 30% disagreed. Consistent with that, only 29% of participants
agreed or strongly agreed that mental health professionals in the UAE are trained to treat and
provide treatment to the LGBT population. This points out to an existence of a barrier in mental
health service delivery to this population.
Around 79% percent agreed or strongly agreed that the lack of mental health services in
the UAE for the LGBT population marginalized them and increased likelihood for mental health
disorders and 74% agreed or strongly agreed that LGBT patients/clients are reluctant to seek
psychological help because of fear of being rejected or persecuted.
Open-Ended Questions
At the end of every sub-scale, there was a designated space for additional comments.
Only 4 participants left brief comments, therefore, due to the insignificant number of comments,
the comments were not coded for specific themes as it was originally intended. Rather some of
the comments were added as quotes in the explanation and analysis of the sub-scales.
Cross Tabulation
The researcher cross tabulated the data obtained to look at whether there were systematic
and significant differences between the perspectives of Emirati and Non-Emirati participants
across the scale, as well as between male and female participants. The Chi-square analysis
showed otherwise, yielding no significant differences (Pearson Chi-square < .05) between the
perspectives of Emirati and non-Emirati participants. Table 6 and table 7 show the Pearson Chi-
square values across the subscale.
Table 6
Chi-square Values Comparison Between Emirati and Non-Emirati Participants.
Subscale Value Significance
Attitude and Beliefs about Family Therapy 15.174 .232
Role of Culture and Religion 24.275 .280
Non-Clinical barriers 12.744 .310
Individuals with Sensitive Issues 15.174 .232
Table 7
Chi-square Values Comparison Between Males and Females Participants.
Subscale Value Significance
Attitude and Beliefs about Family Therapy 16.677 .162
Role of Culture and Religion 21.776 .413
Non-Clinical barriers 26.181 .071
Individuals with Sensitive Issues 11.038 .440
Chapter V
Discussion
In this chapter, the researcher discusses the finding of the study, as well as the
conclusion, clinical implication and the limitation of the present study.
Family therapy is not recognized yet as a form of treatment in the UAE, therefore, family
therapy services do not exist. In addition, there is a lack of family therapy training, supervision,
and education (R. AlShihabi, personal communication, March, 2016). Despite that, the majority
of participants (53%) reported that they are trained in family therapy, while 57% said that they
use family therapy modalities in their clinical work. An explanation might be that participants
were unclear about what constitutes “family therapy”. Participants might have thought that
“family therapy” constitutes inviting family members to participate along with the identified
patient in the individual therapy process, or simply being able to run a therapy session in the
presence of a family member of the identified patient. A study in Turkey indicated that family
therapy is often understood by mental health professionals as the use of individual-focused
approaches while involving family members in treatment without necessarily using systemic-
based interventions. The same study indicated that the lack of regulation in the field of family
therapy has caused confusion and chaos in people’s perception about family therapy (Roberts et
al., 2014). This applies to the UAE as well, since the field of mental health in general is loosely
regulated (Al-Darmaki & Yaqeeib, 2015) and there are no clear distinctions made about different
mental health fields such as psychology and family therapy.
Studying the impact of family dynamics on the well-being of individuals is of particular
importance in the UAE, as rapid economic and cultural developments have caused social and
familial changes (Schvaneveldt et al., 2005). The role family dynamics plays in the wellbeing
and stability of individuals in the UAE is documented in the literature (Naser & Al-Qutob, 2004;
Lambert, 2008). Findings in the present study showed that mental health professionals believed
that families play a major role in clients’ mental health wellbeing. Further, the majority of
participants (92%) reported that engaging family members in treatment planning is crucial.
While the literature lacks information about the benefits of involving Arab family members in
the therapy process, some studies have highlighted the supportive role family members play in
providing care to the patients, which contribute to their overall well-being. For instance, in his
study about the impact of cultural transformation on mental health in Kuwait, Egypt and Qatar,
El- Islam, (2008) stated that it is common for family members to show up with the identified
patients for their appointments or even upon admission to a facility to demonstrate support. The
author also stated that family members usually provide care such as providing transportation and
even contributing to paying medical expenses. In the present study, 87% of participants believed
that treatment is more successful when family members are involved in therapy.
However, the results of the present study also showed that most mental health
professionals believed that it is difficult and inconvenient to engage family members in the
therapy process, with around 61% believing that family members are not willing to engage in the
therapy process. Natrajan-Tyagi (2018) found similar results in her study on mental health
professionals in India, where participants believed that it is difficult to involve family members
in the therapy process. In addition, family members may be disinclined to engage in therapy
because they do not believe that they contribute to the problem, which was a sentiment that 75%
of participants in the present study believed. The majority of participants believed that families
do not seek help when they face psychological problems. Arab families are private, and there are
strong cultural norms against disclosing private family matters to a stranger (Al-Darmaki &
Sayed, 2009; Al-Krenawi et al., 2009). This is also related to the perceived risk of losing face
that comes with disclosing family-related information (Heath et al., 2016) and the heritable
stigma that goes beyond an individual to include other family members, as a result of sharing
family-related information (Naser & Al-Qutob, 2004). Similar results were found in India where
mental health professionals perceived family therapy as potentially high-risk as it reveals family
secrets that can impact the entire family to an unknown outsider (Natrajan-Tyagi, 2018). This
might explain why individual therapy is the preferred method of treatment, where clients either
do not feel the need to disclose family matters or do not risk family members’ losing their face
when they share family matters with their therapists.
Participants’ views regarding the importance of involving family members in therapy
seemed to contradict with their ideas and beliefs about the causes of mental health disorders.
Despite their belief that families played an important role in clients’ mental health wellbeing,
participants seemed to believe that most mental health disorders occurred due to reasons such as
chemical imbalance and temperament rather than family-related issues. This belief can serve as a
big barrier to the practice of Family Therapy in the UAE. This does not come as a surprise,
especially since the mental health field in the Arab world is highly influenced by the medical
model which is individualistic rather than systemic (Al Darmaki & Sulaiman, 2008; Sayed,
2002). Therefore, mental health professionals are not trained to conceptualize cases and provide
treatment from a systemic perspective. Sayed (2002) also believed that the field of mental health
in the Arab world has not evolved beyond what has been exported from the West more than 50
years ago. Therefore, mental health professionals are not exposed to different disciplines in the
field and they feel uncomfortable adopting new methods of treatment. This is similar to a study
in Iran, which indicated that mental health professionals who were trained in family therapy were
less likely to use systemic-based interventions with families when compared to their peers from
the United States (Jaramillo-Sierra et al., 2015). Further, as indicated in the review of literature,
there is little to no awareness about family therapy services in the UAE, which contribute as a
major barrier to providing systemic treatments (R. AlShihabi, personal communication, March,
2016). Similar results were found in India, where the concept of family therapy is foreign to
mental health professionals because of the lack of awareness about family therapy services
(Natrajan-Tyagi, 2018; Roberts et al., 2014).
In western cultures, achieving personal goals and individual success takes precedence
over maintaining family relationships. Therefore, family therapy was developed in the West to
highlight the importance of family relations and to also study the role family dynamics play on
the individuals’ wellbeing. In collectivist cultures, such as the Arab culture, the social structure
emphasizes the cohesiveness of the group, where collective good takes precedence over
individual interest (Lambert, 2008). Individuals are born in extended families, where they learn
from an early age that maintaining harmony between group members is more important than
achieving personal goals. Individuals learn that they do their expected share to maintain the
cohesiveness of the group. Therefore, there may be a preference for more individually focused
therapy that helps clients’ fulfill their individual needs that may have been suppressed by the
collectivistic ideals of the society and family. This may also explain the lack of family therapy
services in the Arab countries as individual therapy may be more sought after than family work.
Mental illness is largely stigmatized in Arab cultures. Participants found that social,
cultural, and religious beliefs may stand as barriers to delivering and accessing mental health and
family therapy services. Eighty eight percent of participants agreed that mental illness is highly
stigmatized in the UAE and 66% agreed that seeking professional help is also stigmatizing. This
is consistent with many studies in the Arab literature (Al-Darmaki, 2003; Al Darmaki, 2014; Al
Darmaki et al, 2016; Heath et al, 2016; Naser & Al-Qutob, 2004). In addition, 71% of
participants agreed that seeking professional help can bring shame and dishonor to the family
name. Al-Darmaki et al, (2016) found similar results in a study conducted on students’ help-
seeking behaviors in the UAE. The finding indicated that fear of bringing shame and dishonor to
the family name was the primary factor preventing individuals from accessing professional help.
Further, around half of the participants in the present study believed that another barrier to
accessing mental health services in the UAE is people’s belief that seeking professional help is
indicative of person’s lack of faith in Allah (God). Therefore, psychological symptoms are
largely viewed as a punishment from God. Seeking help from traditional healers or religious
figures is common in the Arab culture. Around 60% of participants believed that people trust
traditional healers more than mental health professionals. This is consistent with many studies in
the literature indicating that people in the Arab world tend to trust traditional healers more than
in mental health professionals (Al Darmaki et al, 2016; Lawton, & Schulte, 2012; Thomas et al.,
2015). Traditional healers are usually well-versed in the Islamic faith and are also aware of the
various aspects and nuances of the Emirati culture, which the present study indicates is important
to participants (96% agreed that being aware of the cultural, social, and religious aspects of the
Emirati culture is important). Further, traditional healers are part of the culture and have existed
long before the advent of western psychology. People are familiar with traditional healers and
are more comfortable seeking help because no personal information or family secrets are
revealed in the treatment process, which makes it less stigmatizing. In addition, collaborative
modalities where providers and clients work together to find solutions to presenting problems
might not fit well when working with Arab clients (Abudabbeh, 2005). Arab clients trust
providers who assume the expert role, which traditional healers usually assume when providing
services to patients.
In the present study, around 44% of the participants agreed that seeking help from
traditional healers is less stigmatizing than seeking help from mental health professionals and
only 19% disagreed. These results seem less significant than what is indicated in the Arab
literature about the public’s trust in traditional healers in treating mental illnesses (Al Darmaki et
al, 2016; Dardas & Simmons, 2015; Salem et al., 2008; Thomas et al., 2015). This might be
because the population in this study were mental health professionals and academics who are
highly educated, and therefore have better attitudes about mental health than lay people. Another
explanation might be that mental health professionals in the UAE are seeing some changes in the
public’s attitude towards mental health in general. Perhaps people are showing less trust in
traditional healers and are adopting favorable attitudes toward seeking help from mental health
professionals due to the rapid changes and transitions happening in the Emirati society.
The importance of providing mental health services that are culturally appropriate to
Arabs have been well-documented in the literature (Abi-Hashem, 2015; Daneshpour, 2017;
Schvaneveldt et al., 2005) Arab cultures are very old and rooted in history, tradition and faith.
Having a basic knowledge of the Arabic language and respecting the Muslim faith by not
imposing western concepts is of paramount importance when working with Arab families
(Weatherhead & Daiches, 2010). In the present study, 96% of participants agreed that it is
important for mental health providers to be aware of various aspects of the Emirati culture when
working with Emirati clients and families. Further, 87% of participant agreed that Emirati clients
and families prefer to work with a mental health provider who is from a similar cultural
background. Services provided by mental health professionals who are not from a similar
background or who do not consider cultural aspects when working with Emirati individuals and
families might be perceived as a barrier to accessing mental health service by Emirati individuals
and families. In Arab countries, where the population is more homogenous, cultural-competence
training is not emphasized as it is the case in the US, which is primarily a nation of immigrants.
Rather, the therapist is assumed to have the cultural knowledge and use these considerations in
their work. The concept of Multiculturalism is not as evident as in the US. Providers are not
trained to be culturally-sensitive, because they come from similar backgrounds as those of the
clients, and they share similar values, expectations and outlook on life. However, it is essential
for non-Emirati providers to be culturally trained when providing psychotherapeutic services to
Emirati individuals and families.
Barriers to mental health in the UAE include challenges that are non-clinical, such as
funding, policies and regulations. Despite the government’s generous spending and efforts to
improve and promote mental health services in the UAE, there exists a shortage in the number of
qualified mental health professionals in the country. There is also a shortage in the number of
facilities, and community centers that provide mental health services in the UAE (Al-Darmaki &
Yaaqeib, 2015; Alhassani & Osman, 2015). In the present study, 55% of participants agreed that
the funding to mental health services is enough. This contradicts what is well-documented in the
literature. This might be because most of the participants are from The Emirates of Abu Dhabi,
which has the most extensive mental health services in the country (Kraya, 2002). Another
explanation might have to do with people being uncomfortable with criticizing the government
or public policies, as this might be viewed as being ungrateful within the context of the culture.
Around 30% of the population believed that the current level of funding is not enough. Similarly,
around 45% of participants agreed that the governmental strategies to increase awareness about
mental health are in place, while 26% disagreed and 28% were undecided. This indecisiveness
might be indicative of a sort of complacency, which might serve as a barrier to greater progress
in the area of expanding delivery of mental health services.
On the other hand, the majority of participants (73%) thought that the number of mental
health facilities is not enough and around 53% believed that the lack of qualified mental health
professionals contributes to the public distrust in mental health services, which is consistent to
what Al Darmaki and Yaaqieb, (2015) reported in their review of the status of mental health in
the UAE. It seems that participants believed that funding for mental health services is enough,
however, they strongly believed that there are not enough mental health facilities in the country.
These statements sound contradicting. It is possible that participants may have perceived the
question about the government funding as psychologically threatening, especially since the
question had the word “government” in it. Therefore, they may have been inclined to agree that
funding was enough. The question about the number of facilities or the lack thereof may have
been perceived as less threatening because it does not ask directly about a public policy or
government-related issue. In addition, the question about mental health facilities might have been
perceived as asking about either public and/or private facilities, which may have made it easier
for the participants to answer truthfully. These results point out to possible limitations in the
survey which will be discussed in greater detail in the limitations section.
About 73% of the participants agreed that the lack of awareness about mental health
services in the country is one of the major barriers. This also contradicts an earlier finding of the
present study where participant believed that government strategies to raise awareness about
mental health are in place. This finding indicates that there is a gap between the government
strategies to promote mental health services and the public’s awareness about the availability of
mental health services. It might be because the government is not advertising the available
services well enough to the targeted population. It might also be that the public has strong beliefs
against mental health services and are mentally closed off to messages about mental health
services. As the findings of this study indicate, mental illnesses are highly stigmatized, and
cultural and religious beliefs may stand as a barrier to accessing mental health services. It is
possible that these points were not considered in the government strategies to promote mental
health services. At the same time, it is also possible that the governmental strategies that are in
place, may be adequate but not effective. Further inquiry regarding this issue is needed to make
sure that adequate and effective methods are used to spread awareness regarding mental illness
and availability of mental health services in the UAE.
This contradiction between the two previous points may also be because participants, yet
again, were psychologically threatened to answer a question that is related to a government
policy. In general, in the UAE, criticizing public policies and government can be frowned upon
by the public and can be viewed as being ungracious. The government takes exceptional good
care of its citizens by providing free healthcare, education, housing and highly paid jobs to most
of its citizens. Therefore, there is a public sentiment against criticizing government policies. This
has been a topic of discussion and critique recently on social media in the UAE. People have
started to voice their opinions and make the argument that criticizing a government policy does
not equate to being treasonous or disloyal to the country. Inability or fear of voicing one’s
opinion about the lack of services might be a contributing factor to creating barriers to receiving
improved mental health services and to further progress the mental health field in the country.
The UAE is a federation that consists of seven emirates. Individuals in major emirates
such as Abu Dhabi, Dubai, and to a less extent, Sharjah, enjoy access to decent mental health
services (Kraya, 2002). However, mental health services in the northern Emirates (Ajman, Ras
Al-Khaimah, Um AL Quwain and Fujairah) are underdeveloped at best and have long been
neglected. In this study, 62% of participants believed that people in northern emirates have
inadequate mental health services and around 70% believed that people in northern emirates
would utilize mental health services more often if there were adequate services in their
geographical location. Further, 73% believed that the traveling distance for individuals from
northern emirates is a barrier to utilizing mental health services. It is common for people from
Northern Emirates to travel to major cities to access mental health services. Recently however,
the federal government have opened new hospitals or psychology clinics in some northern
Emirates, such as Ajman, Ras Al-Khaimah and Fujairah. More mental health services and
facilities are needed in these areas to ensure that individuals have adequate access to basic
mental health services. The lack of available services in northern emirates stands as one of the
major barriers to accessing and receiving mental health services, which can jeopardize the mental
wellbeing of individuals.
Among the many challenges in the mental health field, the lack of laws and regulations
stands as one of the most striking. Until this day, a mental health policy does not exist, rather,
there is a mental health act that is part of the general healthcare act. The lack of regulations have
negatively impacted the public trust in the mental health field (Al Darmaki & Yaaqeib, 2015),
and also enabled some fraudulent mental health workers to exploit patients and commit illegal or
unethical practices (Alshihabi, 2014; Badawi, 2012; Bell, 2014; Bill & Rizvi, 2014). There have
been numerous calls from within the field for legislatures to create a mental health act with
clearer laws and regulations. In this study, 73% of participants believed that there is a need for an
updated mental health act that is separate from the general healthcare plan. In addition, 89% of
participants believed that the public would trust mental health services and use it more often if
there were clearer laws and regulations. Participants also believed that unified mental health
licensure requirements across the country would better regulate and improve the practice of
mental health in the UAE. Currently, different emirates have different regulatory bodies and
licensure requirements and these requirements vary considerably, which creates chaos and
confusion in the field.
In the present study, the researcher examined barriers related to individuals from the Gay,
Lesbian, Bisexual and Transgender community (LGBT). Issues related to LGBT population are
rarely addressed in the UAE. Until this day, being gay, lesbian, transgender or bisexual is widely
viewed as a “sexual deviation” that needs to be corrected and treated. Homosexuality is
condemned religiously and is considered illegal (S, Alfardan, Personal communication, October,
2017). About 74% agreed or strongly agreed that LGBT individuals are reluctant to seek
psychological help because of fear of being rejected or persecuted. This is very concerning as
social barriers (based on an individual’s sexual orientation) to accessing mental health treatment
will only lead these individuals to further deteriorate in terms of their mental health wellbeing.
About 79% agreed that the lack of services to the LGBT population marginalizes them and
exposes them to isolation and increases the likelihood to mental disorders. To date, there is only
one published article that talks about lesbian identity in the UAE (Al-Qasimi, 2011). However, in
the recent years, things have seen a slight change. For example, gender-reassignment surgeries
are now legal. Further, there is a growing attitude in the mental health field against providing
conversation therapy with an increase of professionals who provide affirmative therapy even in
public hospitals that are run by the government (R. AlShihabi, personal communication, March,
2016). In this study, 94% of the participants believed that there is a need to provide culturally
sensitive training to mental health professionals, so they can better address issues related with to
LGBT population. Similarly, 85% agreed that there is a need to provide safe environment for
LGBT patients/clients so they can express issues related to them. While there are no imminent
threats in providing services to LGBT individuals, as indicated earlier 79% of participants
believed that individuals of the LGBT community might be under the impression that it is
dangerous to seek help, out of fear of being publicly outed, judged or even persecuted. This also
might be indicative to the lack of trust the LGBT community has toward mental health
professionals. The study found that only 32% agreed that mental health professionals are
comfortable in addressing LGBT-related issues with their clients and 29% agreed that mental
health professionals are trained to treat sensitive issues related to the LGBT population. In Arab
countries, issues related to sexual minorities and LGBT issues are still perceived as powerful
taboos and are highly stigmatized, as a result, these issues are usually left unaddressed in the
therapy room (Jaspal & Cinnirella, 2012).
In general, the majority of participants saw the need to offer adequate services to LGBT
individuals in the UAE and acknowledged the necessity to provide a safe space where they
community can comfortably express issues related to them. These positive attitudes towards the
LBGT population might be driven by the recent international wave of acceptance of sexual
minorities in western countries, which have positively impacted the perceptions of people in less
accepting countries towards the LGBT population (Wight, 2017).The UAE has been a model
country in the Arab region that takes pride in the diversity of its population and promotes values
of acceptance, co-existence and harmony (Davidson, 2008). In an effort to maintain this image,
the country may have adopted a more lenient attitude toward LGBT population. Al-Qasimi,
(2011) believe that the country is in a dilemma between staying true to its traditional values
while also showing positive attitudes toward new pressing social causes such as the cause of
integrating and accepting sexual minorities into the mainstream society.
Clinical and Research Implications.
The study has numerous implications for clinicians and researchers. Family therapy is
nonexistent in the UAE. Therefore, many systemic issues remain unaddressed in the therapy
room. Given the collectivistic nature of the family structure and the role family dynamics play in
the wellbeing of the individuals, family therapy would be of paramount benefit. There is a need
for institutions that offer training in family therapy modalities where mental health professionals
learn how to address systemic issues and look at symptoms from a systemic perspective,
especially since the study revealed that mental health professionals are heavily influenced by the
medical model, which often overlooks systemic perspectives. Systemic training includes the
ability to delicately address issues, such as power, gender-role and communication style in the
system and validating all perspectives without crossing cultural or religious norms or imposing
western practices or notions of what constitutes right or wrong and health or sickness. Further,
along with systemic therapy modalities, it is important for mental health professionals to be
culturally competent and aware of cultural and social aspects when working with Emirati clients
and families. For example, when providing family therapy, it is essential to approach issues
related to hierarchy and gender-roles from a culturally appropriate perspective, as these concepts
have different meanings within the Arab culture. Traditionally, fathers or husbands are the head
of the family unit and, unless otherwise indicated, should be approached in therapy as such. At
the same time, the views of women and wives should also be acknowledged and validated in
therapy. Therapists need to use their clinical judgment to differentiate between respecting
traditional values and perpetuating oppressive practices against women or any other minorities.
Further, marriages are usually traditional and are rooted in the practice of traditional gender
roles. Imposing egalitarian views (unless it is desired by the family) might be seen offensive and
emasculating. Polygamy, even though not as common as it once was, is still acceptable in Most
Arab societies. Providers should also be sensitive not to pathologize polygamy as it has been
practiced for thousand of years in the Arab and Muslim cultures.
Consistent with many studies in the Arab mental health literature, this study showed that
stigma is still one of the major barriers in accessing mental health services. Emiratis’ cultural,
social and religious beliefs have to be taken into consideration when creating new policies and
campaigns that aims to bridge the gap between the government strategies and the public
awareness about mental health issues. For instance, campaigns can collaborate with traditional
healers, religious figures and celebrities to promote mental health services and help break down
barriers that contribute to stigma, especially in northern emirates and rural areas where the study
indicated that access to mental health services is significantly harder. The study also indicated
that the lack of regulations has a negative impact on the public’s trust of the mental health field.
Stricter regulations and licensure requirements are needed to increase the level of competency
and enhance the level of practice, which is likely to increase the public’s trust toward the mental
health field. Different licensure bodies from different emirates (e.g., Health Authority-Abu
Dhabi, Dubai Health Authority, Sharjah Health Authority and the Ministry of Health) can hold
meetings and create platforms across different emirates where discussions can be facilitated that
aim to create better licensure requirements that ensure better and more regulated practices of
psychology across the country. Prominent mental health professionals can also meet with
members of the National Federal Council or other local legislative bodies in different emirates to
present about the importance of creating stricter laws and regulations as well as licensure
requirements for mental health professionals.
In addition, the study indicated that there is a huge lack of services geared toward sexual
minorities and issues related to the LGBT population. There is a need to provide training to
mental health professionals so they can provide evidence-based affirmative therapies to
individuals of the LGBT community. Outreach programs should be created to recruit individuals
of the LGBT community, especially that the study indicated that LGBT individuals might be
reluctant to access mental health services out of fear of judgment or even persecution. As an
initial step, a national crisis line can be established to offer help and guidance for LGBT
individuals and individuals with sensitive issues, who are in need for mental health services yet
are fearful to seek help. In addition, school counselors can be trained to proactively look for
students who might be struggling with symptoms of gender dysphoria or issues related to sexual
identity/orientation and refer them to mental health professionals who are trained to work with
individuals presenting with such issues.
The study yielded surprisingly positive attitudes towards the LGBT community in the
UAE. The study indicated that there is a consensus among mental health professionals in the
country to provide culturally sensitive therapies to individuals of the LGBT community. This
consensus among mental health professionals in the current study might be indicative of how
prevalent the issue is becoming. It might indicate that, in their clinical work, mental health
professionals have been recently witnessing an increasing number of LGBT-related issues
manifesting in the therapy room. Questions should be asked about the capacity in which these
issues are manifesting. Whether they are manifesting in marital issues, schools-related issues,
parent-child relationships, self-harm behavior, substance misuse, or other capacities. The answer
to these questions can provide insight to clinicians that may enable them to address these issues
as they happen rather than to wait until it is too late. A dialogue about LGBT patients’ needs, as
well as an initiative to not pathologize individuals of the LGBT community is needed. Cultural
and religious barriers should be addressed in order to provide evidence-based practices that
improve the quality of life of the LGBT community. However, when discussing LGBT-related
issues with the public, providers should be cautious about what topics they discuss. For instance,
a conversation about greater civil rights might be inappropriate at this time. As a country, the
UAE is still behind in terms of laws and regulations regarding LGBT rights. Moreover, the
public has very strong negative views toward the LGBT community. Therefore, the society
might not be ready to have this conversation yet. A better step would be to educate the public
about the LGBT community and correct some of the distorted images the public has toward
them. Another step would be to advocate for more services that are tailored to the community, by
providing culturally-sensitive training to mental health providers, so they can deliver better
quality services to the individuals of the LGBT community. In doing so, mental health providers
should be delicate and sensitive to the local culture. It may be beneficial to send validating
messages to the public and the religious community, acknowledging their beliefs about the
issues, yet at the same time, advocate for more understanding and services for the LGBT
community. For example, while working with the LGBT community, providers may inform the
public that by doing so, they are not trying to impose any western agendas, rather, they are
offering psychological help to a population that has long been neglected.
More qualitative studies, such as focus group studies are needed to further explore the
various perspectives of mental health professionals in the UAE regarding barriers to accessing
mental health services in the UAE. This will help gain a more in-depth understanding of their
perspectives regarding barriers to mental health delivery and potential solutions to these barriers.
Moreover, more research is needed to explore the publics’ perspective about barriers to mental
health services in the UAE to compare the findings and to help bridge the gap between the
mental health professional perspectives and public’s perspective. Finally, researcher should be
cautious about asking direct questions about government policy or government funding as the
word “government” can be psychologically threatening to participants.
Limitation of the Study
There were few limitations in the study. First, participants were only from major cities in
the UAE (mainly Abu Dhabi). Therefore, participants’ perspectives may have been influenced by
the abundance of mental health services in Abu Dhabi when compared to other Emirates.
Further, mental health barriers specific to the other Emirates were left uncovered. Second,
around 20% of participants were non-Arab expatriates, who might not be well-informed about
cultural and social issues and challenges experienced in the Emirati culture. Third, some
questions in the survey were double-negatives, which may have confused the participants. This
might explain the reason behind the significant differences in participants’ response to some of
the questions that measure similar items. Finally, some questions that asked direct questions
about government policies or government funding might have been perceived as psychologically
threatening, thus leading to inconsistent answers from the participants.

References
Abed, A. (2014, November 12). 33 thousand mental patients suffering from shortage of
psychotherapists. Emarat AlYoum. Retrieved on March. 1, 2017, from
http://www.emaratalyoum.com/local-section/other/2014-11-12-1.727351 [In Arabic].
Abi-Hashem, N. (2014). Cross-cultural psychology and counseling: A Middle Eastern
perspective. Journal of Psychology And Christianity, 33(2), 156-163. Okasha, A. (2003).
Mental health services in the Arab world. Arab studies quarterly,
Abou-Saleh, M.T., Ghubash, R., & Daradkeh, T.K. (2001). Alain community psychiatric
survey: Prevalence and socio-demographic correlates. Social Psychiatry and Psychiatric
Epidemiology, 36, 20-28.
Abudabbeh, N. (2005). Arab Families: An Overview. In M. McGoldrick, J. Giordano, N. Garcia-
Preto, M. McGoldrick, J. Giordano, N. Garcia-Preto (Eds.), Ethnicity and family therapy,
3rd ed (pp. 423-436). New York, ny, us: Guilford press.
Al-Darmaki, f. R. (2003). Attitudes towards seeking professional psychological help: what really
counts for united Arab emirates university students?. Social Behavior & Personality: An
International Journal, 31(5), 497-508. doi:10.2224/sbp.2003.31.5.497
Al-Darmaki, F. (2011). Needs, Attitudes Toward Seeking Professional Help, and Preferred
Sources of Help Among Emirati College Students. Journal for International Counselor
Education, 3, 39-57.
Al-Darmaki, F., & Sayed, M. A. (2009). Counseling challenges within the cultural context of the
United Arab Emirates. In L. H. Gerstein, P. P. Heppner, S. Ægisdóttir, S. A. Leung, K. L.
Norsworthy, L. H. Gerstein, K. L. Norsworthy (Eds.), International handbook of cross-
cultural counseling: Cultural assumptions and practices worldwide (pp. 465-474).
Thousand Oaks, CA, US: Sage Publications, Inc. doi:10.4135/.n35
Al Darmaki, F., & Sulaiman, S. (2008). Counseling within a changing world:. In Biennial
Review of Counseling Psychology (1st ed., Vol. 1, pp. 232-236). New York: Routledge.
Al-Darmaki, F., Thomas, J., & Yaaqeib, S. (2016). Mental Health Beliefs Amongst Emirati
Female College Students. Community Mental Health Journal, 52(2), 233-238.
doi:10.1007/s10597-015-9918-9
Al-Darmaki, F., & Yaaqeib, S. (2015). Psychology and mental health services in the United Arab
Emirates. Psychology International, 26(2). 1-4.
Al Gharaibeh, F., & Bromfield, N. F. (2012). An Analysis of Divorce Cases in the United Arab
Emirates: A Rising Trend. Journal Of Divorce & Remarriage, 53(6), 436-452.
doi:10.1080/10502556.2012.6828
Alhassani, G., & Osman, O. T. (2015). Mental health law profile: The United Arab Emirates.
Bjpsych International, 12(3), 70-72.
Al-Krenawi, A. (2002). Mental Health Service Utilization Among the Arabs in Israel. Social
Work in Health Care, 35(1/2), 577-589.
Al-Krenawi, A., Jackson, A. C., & Segal, S. P. (2002). MENTAL HEALTH: EVALUATING
SYSTEM FIT WITH NEED: Mental Health Service Utilization Among the Arabs in
Israel. Social Work Health & Mental Health: Practice, Research & Programs, 577-589.
Al-Maseeh, H. (2013). Licensing psychology — no closer to a unified system? The UAE
Psychologist. 2(2), 5.
Al Mualla, S. (2011). Psychiatric Services in Dubai (A Short Descriptive Report). International
Journal of Mental Health And Addiction, 9(2), 219-225.
Alnowais, S, (2015, May, 27). Polygamy with equality is ‘impossible’, says Emirati spouse. The
National retrieved on Feb. 23, 2018, from: https://www.thenational.ae/uae/polygamy-
with-equality-is-impossible-says-emirati-spouse-1.120356
Al-Qasimi, N. (2011). Ladies and gentlemen, boyahs and girls: Uploading transnational queer
subjectivities in the United Arab Emirates. In R. S. Hegde, R. S. Hegde (Eds.), Circuits of
visibility: Gender and transnational media cultures (pp. 284-302). New York, NY, US:
New York University Press.
AlShihabi, R. (2011). Licensing needs for psychologists in Abu Dhabi. The UAE Psychologist.
1(2), 4.
Amnesty International. (2016) The Corruption Perception Index. Retrieved from
http://www.transparency.org/news/feature/corruption_perceptions_index_2016.
Badawi, I. (2012). The role of psychologists in promoting mental health in the UAE. The UAE
Psychologist. 1(2), 12-13.
Barakat, H. (2007). The Arab world: society, culture, and state. Berkeley, CA: University of
California Press.
Bebbington, P., Hamdi, E., & Ghubash, R. (1998). The Dubai Community Psychiatric Survey:
IV. Life events, chronic difficulties and psychiatric morbidity. Social Psychiatry &
Psychiatric Epidemiology, 33(10), 501.

Bill, J. (2014, October 23). Mental health is one of biggest challenges facing the UAE. The
National. Retrieved from http://www.telegraph.co.uk/expat/life/living-in-dubai-why-
dont-expats-integrate-with-emiratis/
Bobrick, B. (2012). The Calih's Splendor: Islam and the West in the Golden Age of Baghdad.
New York: Simon & schuster.
Brinson, J. A., & Al-amri, F. S. (2006). Students' Perceptions of Mental Health Counseling in the
United Arab Emirates (UAE). International Journal for The Advancement Of
Counselling, 27(4), 495-512. doi:10.1007/s10447-005-8487-y
Crabtree, S. A. (2007). Culture, gender and the influence of social change amongst Emirati
families in the United Arab Emirates. Journal Of Comparative Family Studies, 38(4), 575-
587.
Creswell, J. W. (2007). Qualitative inquiry & research design: Choosing among five
Approaches (3rd ed.). Thousand Oaks: Sage Publication
Dalky, H. F. (2012). Perception and coping with stigma of mental illness: Arab families’
perspectives. Issues in Mental Health Nursing, 33(7), 486-491.
doi:10.3109/01612840.2012.676720
Daoud, N., Shoham-Vardi, I., Urquia, M. L., & O'Campo, P. (2014). Polygamy and poor mental
health among Arab Bedouin women: Do socioeconomic position and social support
matter? Ethnicity & Health, 19(4), 385-405. doi:10.1080/13557858.2013.801403
Dardas, L. A., & Simmons, L. A. (2015). The stigma of mental illness in Arab families: a
concept analysis. Journal of Psychiatric & Mental Health Nursing, 22(9), 668-679.
doi:10.1111/jpm.12237
Daneshpour, M. (2017). Family therapy with Muslims. New York: Routledge.
Demography, Migration, and the Labour Market in the UAE (Rep.). (2015).
doi:http://cadmus.eui.eu/bitstream/handle/1814/36375/GLMM_ExpNote_07_2015.pdf
Hamdan, A. (2009). Mental Health Needs of Arab Women. Health Care for Women
International, 30(7), 595-613. doi:10.1080/07399330902928808
DeVellis, R. F. (2003). Scale development: Theory and applications. Thousand Oaks, CA: Sage
Publications.
Eapen, V., & Ghubash, R. (2004). Help-seeking for mental health problems of children:
Preferences and attitudes in the United Arab Emirates. Psychological Reports, 94, 663–
667. doi:10.2466/pr0.94.2.663-667
Eapen, V., Jakka, M. E., & Abou-Saleh, M. T. (2003). Children with psychiatric
disorders: The Alain community psychiatric survey. Canadian Journal of Psychiatry,
48(6), 402-407. Retrieved from
http://ww1.cpaapc.org:8080/Publications/Archives/CJP/2003/july/eapen.asp
El-Islam, M. F. (2008). Arab culture and mental health care. Transcultural Psychiatry, 45(4),
671-682. doi:10.1177/1363461508100788
Ghubash, R., & El-Rufaie, O. (1997). Psychiatric morbidity among sentenced male prisoners in
Dubai: Transcultural perspectives. The Journal of Forensic Psychiatry, 8(2), 440-446.
Ghubash, R., El-Rufaie, O., Zoubeidi, T., Al-Shboul, Q. M., & Sabri, S. M. (2004). Profile of
mental disorders among the elderly United Arab Emirates population: sociodemographic
correlates. International Journal Of Geriatric Psychiatry, 19(4), 344-351.
doi:10.1002/gps.1101
Ghubash, R., Daradkeh, T. K., Al-Muzafari, M. A., Manssori, M. E., & Abou-Saleh, M. T.
(2001). Al Ain community psychiatric survey IV: Socio-cultural changes (traditionality-
liberalism) and prevalence of psychiatric disorders. Social Psychiatry and Psychiatric
Epidemiology, 36, 565–570.
Golley, N. (2004). Is feminism relevant to Arab women?. Third World Quarterly, 25(3), 521-
536
Green, K. E., & Smith, D. E. (2007). Change and continuity: Childbirth and parenting across
three generations of women in the United Arab Emirates. Child: Care, Health And
Development, 33(3), 266-274. doi:10.1111/j.1365-2214.2006.00667.x
Hamdi, E., Gawad, T., Khoweiled, A., Sidrak, A. E., Amer, D., Mamdouh, R., & ... Loza, N.
(2013). Lifetime prevalence of alcohol and substance use in Egypt: A community survey.
Substance Abuse, 34(2), 97-104. doi:10.1080/08897077.2012.677752
Hamza, S. (2015). Migrant Labor in the Arabian Gulf: A Case Study of Dubai, UAE. Pursuit:
The Journal Of Undergraduate Research At The University Of Tennessee, 6(1), 81-114.
Hale, J. (2011). The 3 basic types of descriptive research methods. Psych Central.
Retrieved from http://psychcentral.com/blog/archives/201 l/09/27/the-3-basictypes-
of-descriptive-research-methods/
Heath, P. J., Vogel, D. L., & Al-Darmaki, F. R. (2016). Help-seeking attitudes of United Arab
Emirates students: Examining loss of face, stigma, and self-disclosure. The Counseling
Psychologist, 44(3), 331-352. doi:10.1177/0011000015621149
Hodge, D. R., Zidan, T., & Husain, A. (2016). Depression among Muslims in the United States:
Examining the Role of Discrimination and Spirituality as Risk and Protective Factors.
Social Work, 61(1), 45-52. doi:10.1093/sw/swv055

Jabbour, S., & Yamout, R. (2012). Public health in the Arab world. Cambridge: Cambridge
University Press.
Jaspal, R., & Cinnirella, M. (2012). Identity Processes, Threat, and Interpersonal Relations:
Accounts From British Muslim Gay Men. Journal Of Homosexuality, 59(2), 215-240.
doi:10.1080/00918369.2012.638551
Kantaria, A. (2016, March 26). Living in Dubai. Why don’t expats integrate with Emiratis. The
Telegraph. Retrieved from http://www.telegraph.co.uk/expat/life/living-in-dubai-why-
dont-expats-integrate-with-emiratis/
Kaslow, F., Phipps, W., Reid, F. T., & Gillespie, J. (2013). Family Therapy Around the World:
Collaboration Among and Across Religions and Cultures. International Family Therapy
Association's 21St World Family Therapy Congress, Orlando, Florida, February 20-23,
2013: Book Of Abstracts, 5. doi:10.1037/e635102013-005
Khalaf, H. (2016, November 22) Mental health in the UAE: Alternative ways to find affordable
therapy. The National. Retrieved from http://www.thenational.ae/arts-life/well-
being/mental-health-in-the-uae-alternative-ways-to-find-affordable-therapy
Kjeilen, T. (2013). United Arab Emirates. Encyclopedia of the Orient. Retrieved February 28,
2013, from http://www.icias.com/e.o/uae_5.ht,
Kruse, M. (2011). Emirates psychological association: A brief introduction. The UAE
Psychologist.1(2),6.
Kumar, P. (2011). What is descriptive research method! Retrieved from http://www.pre
servearticles.com/2012022523769/what-is-descriptive-research-method.html
Lambert, L. (2008). A Counselling Model for Young Women in the United Arab Emirates:
Cultural Considerations. Canadian Journal of Counselling, 42(2), 101-116.

Loffredo, C. A., Boulos, D. K., Saleh, D. A., Jillson, I. A., Garas, M., Loza, N., & Amr, S.
(2015). Substance Use by Egyptian Youth: Current Patterns and Potential Avenues for
Prevention. Substance Use & Misuse, 50(5), 609-618.
doi:10.3109/10826084.2014.997391
Lawton, J., & Schulte, S. (2012). The Prevalence of Mental Health Symptoms Among
Outpatients in The United Arab Emirates. The Arab Journal of Psychiatry ,23(2), 138-
147.
Luna, N., & MacMillan, T. (2015). The relationship between spirituality and depressive
symptom severity, psychosocial functioning impairment, and quality of life: examining
the impact of age, gender, and ethnic differences. Mental Health, Religion & Culture,
18(6), 513-525. doi:10.1080/13674676.2015.1087481
Mertens, D. M. (2004). Research and Evaluation in Education and Psychology: Integrating
Diversity with Quantitative, Qualitative, and Mixed Methods. Second Edition. SAGE
Publications (CA).
Mertler, C., & Charles, C.M. (2005). Introduction to educational research. Boston, MA:
Pearson.
Moselhy, H. F., Ghubach, R., El-Rufaie, O., Zoubeidi, T., Badrinath, P., Sabri, S., & Yousef, S.
(2012). The association of depression and anxiety with unhealthy lifestyle among United
Arab Emirates adults. Epidemiology and Psychiatric Sciences, 21(2), 213-219.
doi:10.1017/S2045796011000709
Muijs D. (2004). Doing quantitative research in education with SPSS. Thousand Oaks,
CA: Sage.
Nasir, L. S., & Al-Qutob, R. (2005). Barriers to the diagnosis and treatment of depression in
Jordan. A nationwide qualitative study. The Journal of The American Board Of Family
Practice, 18(2), 125-131.
Okasha, A. (1999). Mental health services in the Arab world. Eastern Mediterranean Health
Journal = La Revue De Sante De La Mediterranee Orientale = Al-Majallah Al-Sihhiyah
Li-Sharq Al-Mutawassit, 5(2), 223-230.
Okasha, A., el Akabawi, A.S., Snyder, K. S., Wilson, A. K., Youssef, I., & el Dawla, ,A.S.
(1994). Expressed emotion, perceived criticism, and relapse in depression: A replication
in an Egyptian community. The American Journal of Psychiatry, 151(7), 1001-Retrived
from
5.http://0search.proquest.com.library.alliant.edu/docview/220439945?accountid=25255
Okasha, A., Saad, A., Khalil, A. H., Seif-El-Dawla, A., & Yehia, N. (1994). Phenomenology
of OCD: A transcultural study. Comprehensive Psychiatry, 35, 191–197.
Osman, O. T., & Afifi, M. (2010). Troubled minds in the gulf: Mental health research in the
United Arab Emirates (1989-2008). Asia-Pacific Journal of Public Health, 22(3, Suppl),
48S-53S. doi:10.1177/1010539510373025
Peck, M. (2004). Sheikh Zayed and the Passage of the United Arab Emirates into the Modern
World: The Uses of the Past. Journal of Social Affairs, 21(84), 29-41.
Rizvi, J. & Bell, J., (2014, October 23). Mental health act needed in UAE. The National.
Retrieved on Feb. 3, 2015, from http://www.gncdubai.com/mental-health-act-needed-
uae-national/.
Roberts, J., Abu-Baker, K., Fernández, C. D., Garcia, N. C., Fredman, G., Kamya, H., . . . Vega,
R. Z. (2014). Up Close: Family Therapy Challenges and Innovations Around the World.
Family Process, 53(3), 544-576. doi:10.1111/famp.12093
Salem, M. O., Saleh, B., Yousef, S., & Sabri, S. (2009). Help-seeking behaviour of patients
attending the psychiatric service in a sample of United Arab Emirates population.
International Journal Of Social Psychiatry, 55(2), 141-148.
doi:10.1177/0020764008093373
Samier, E. (2015). Emirati Women's Higher Educational Leadership Formation under
Globalisation: Culture, Religion, Politics, and the Dialectics of Modernisation. Gender
and Education, 27(3), 239-254.
Sayed, M. A. (2002). Arabic Psychiatry and Psychology: The physician who is a philosopher and
the physician who is not a philosopher: some cultural considerations. Social Behavior &
Personality: An International Journal, 30(3), 235-241. doi:10.2224/sbp.2002.30.3.235
Schvaneveldt, P. L., Kerpelman, J. L., & Schvaneveldt, J. D. (2005). Generational and Cultural
Changes in Family Life in the United Arab Emirates: A Comparison of Mothers and
Daughters. Journal of Comparative Family Studies, 36(1), 77-91.
Shepard, L. D. (2013). The impact of polygamy on women’s mental health: A systematic review.
Epidemiology and Psychiatric Sciences, 22(1), 47-62. doi:10.1017/S2045796012000121
Sternthal, M. J., Williams, D. R., Musick, M. A., & Buck, A. C. (2012). Religious practices,
beliefs, and mental health: Variations across ethnicity. Ethnicity & Health, 17(1-2), 171-
185. doi:10.1080/13557858.2012.655264
Sulaiman, N., Hamdan, A., Tamim, H., Mahmood, D. A., & Young, D. (2010). The prevalence
and correlates of depression and anxiety in a sample of diabetic patients in Sharjah,
United Arab Emirates. BMC Family Practice, 1180-86. doi:10.1186/1471-2296-11-80
Sulaiman, M. A., Moussa, M. A. A., & El-Islam, M. F. (1989). The profile of parasuicide
repeaters in Kuwait. International Journal of Social Psychiatry, 35, 146–155.
Tabachnick, B. G., & Fidell, L. S. (2013). Using multivariate statistics. Boston: Pearson
Educatio
The World Economic Forum. (2017) The Annual Infrastructure Report. Retrieved from
https://www.weforum.org/reports/risk-mitigation-instruments-in-infrastructure-gap-
assessment
Thomas, J., Al-Qarni, N., & Furber, S. W. (2015). Conceptualising mental health in the United
Arab Emirates: the perspective of traditional healers. Mental Health, Religion & Culture,
18(2), 134-145. doi:10.1080/13674676.2015.1010196
United Arab Emirates, National Bureau of Statistics. (2011). Population estimates 2006-
2010. Retrieved from http://www.uaestatistics.gov.ae/EnglishHome/ReportDetails
United Nations Development Programme. (2003). The Arab human development report:
Building a knowledge society. New York: Author.
United Nations Office for Drug Control & Crime Prevention (UNODCCP). (2001). Rapid
assessment of trends and patterns of drug abuse in Egypt. Cairo, Egypt: United Nations
Office for Drug Control & Crime Prevention.

World Health Organization (2011). Mental Health Atlas Country Profiles. Retrieved on Feb., 29,
2017 fromhttp://www.who.int/mental_health/evidence/atlas/profiles/are_mh_profile.pdf (PDF,
113KB).
Wight, C. (2017). Querying the queer wars. Australian Journal of International Affairs, 71(3),
247-254. doi:10.1080/10357718.2017.1290048
Appendix A
Age:
18-24 25-34 35-44 45-54 older than 55 I prefer not to say
Gender:
Male Female
Highest level of Education:

High school Diploma/Technical Diploma Bachelor’s degree Master’s Degree
PhD Degree Medical Degree (MD) Other: please specify______________
Current Occupation:
Psychologist Social worker counselor Academic Psychiatrist Psychiatric nurse
Researcher occupational therapist Other: please specify ___________________
Sector:
Public sector Private sector Other: please specify_____________________
Nationality_________________________________________________________________
Religion:
Muslim Christian Catholic Jewish Buddhist Hindu Sikh Non-religious
prefer not to say Other
Languages Spoken :_______________________________________________

Appendix B
The Survey
The statements below explore issues experienced by mental health professionals about barriers to
delivering and accessing mental health services in the UAE. The survey consists of 4 different
parts. Each part explores a specific type of barriers: barriers due to beliefs and attitudes about
Family Therapy, role of culture, religion and stigma, non-clinical barriers and barriers due to
delivery and accessibility of services. Please read each statement carefully and mark the answer
that you agree with the most.
There are no right or wrong answers. Respond honestly to the statements from your own point
of view using the following scale:
1. Strongly Disagree 2.Disagree 3.Neither Agree nor Disagree 4.Agree 5.Strongly Agree
Beliefs and Attitudes of Clinicians about Family Therapy
Neither Agree nor
Strongly Disagree
Strongly Agree
Disagree
Disagree
Agree
1. The type of relationship patients/clients have with

their immediate family members play a strong role in
their psychological stability and wellbeing.
2. While creating treatment plans for patients/clients, it

is important to engage family members and discuss
their role in the problem and their role in the
resolution of the problem.
3. Most mental health disorders occur due to reasons

such as patients’ temperament, chemical imbalance, or
intrapersonal reasons, rather than family-related
factors.
4. Treatment of mental health patients/clients is

successful when family members are brought into
therapy.
5. Family members are willing to participate in therapy

sessions with the identified patient/client.
6. I am trained in Family Therapy.

7. I often use Family Therapy as one of the treatment
modalities in my clinical work.
8. Family members often do not see themselves as
contributing to the mental health problems of the
identified patient/client.
9. It is easy to bring members of the family into the
hospital or other mental health facility to be part of the
therapy/treatment.
10. Families seek psychological therapy when they
experience family issues (e.g., domestic violence,
parent-child problems, marital conflicts, teenage
problems etc.).
Please add additional comments (needs, challenges
and/or suggestions that you may have regarding
Clinical Barriers to Family Therapy.
Role of Culture, Religion and Stigma
Neither Agree nor
Strongly Disagree
Strongly Agree
Disagree
Disagree
Agree
11. Mental illnesses are highly stigmatized in the Emirati
culture.
12. Seeking psychological help for family problems is

stigmatized in the Emirati culture.
13. Stigma of seeking professional help is the main reason
for underutilizing mental health services in the UAE.
14. People prefer seeking traditional methods of help (e.g.,

mutawas, religious healers, etc) for psychological
problems.
15. People trust traditional healers more than mental health
professionals in treating mental health problems.
16. Seeking help from mental health professionals is more
stigmatizing than seeking help from
traditional/religious healers.
17. people are often reluctant to seek mental health services
because of their fear to bring shame to the family.
18. Approaching mental health issues from the medical
model that diagnosis and pathologizes, reinforces
stigma.
19. People believe that seeking mental health services is a
sign of weakness in the person.
20. People believe that seeking psychological help is

indicative to the person’s lack of faith in Allah (God).
21. The concepts of psychotherapy, psychiatry and family
therapy are foreign to the local culture.
22. Knowledge of the Arabic language is important in
providing mental health services.
23. It is important for mental health professionals to be
aware of cultural, social, and familial aspects of the
Emirati culture.
24. Clients and families in the UAE tend to trust mental

health providers who are of the same culture or
background.
25. Cultural, and religious background of the mental health

provider is not a barrier to providing mental health
services to Emirati patients/clients.
Please add additional comments, needs, challenges
and/or suggestions that you may have regarding Role of
Culture, Religion and Stigma.
Non-clinical Barriers to Mental Health
Neither Agree nor
Strongly Disagree
Strongly Agree
Disagree
Disagree
Agree
26. The governmental funding for mental health services

across the UAE is adequate.
27. The shortage of qualified mental health professionals

across the UAE contributes to the lack of public
confidence in the mental health services.
28. The current number of mental health facilities is
enough, and there is no need for more mental health
facilities across the UAE.
29. Northern emirates and rural areas have adequate mental

health services and facilities.
30. The travelling distance is one of the barriers to using
mental health services in the northern emirates and
rural areas of the UAE.
31. People in northern emirates and rural areas would use

mental health services more often if there were
adequate services available in their geographical
location.
32. Lack of awareness about the availability of mental

health services is one of the reasons for underutilization
of mental health services in UAE.
33. Adequate Information about mental health services and
providers are made available to the public in the UAE.
34. Governmental strategies that aim to increase the

public’s awareness of the benefits of mental health
services are in place.
35. Mental health strategies and campaigns are needed to
increase the public accessibility to mental health
services in the UAE.
36. I am aware of an existing Mental Health Act in the
UAE.
37. The existing Mental Health Act ensures the rights and
responsibilities of patients and their families.
38. A new and independent mental health policy that is

separate from the general health policy is needed.
39. It is important that the rights of patients, (e.g. rights to

consent) is protected in the new mental health policy.
40. Individuals would trust mental health services and use

it more often if there were clear mental health policies
and regulations.
41. Patients with mental health issues in the UAE have less
rights compared to those in other countries.
42. A unified mental health licensure requirements and
procedures across the UAE would improve the practice
of mental health services.
Please add additional comments, needs, challenges

and/or suggestions that you may have regarding Non-
clinical Barriers to Mental Health
Delivery and Accessibility of Services to Populations with Sensitive Issues

Neither Agree nor
Strongly Disagree
Strongly Agree
Disagree
Disagree
Agree
43. There is a need to provide culturally sensitive training
to practicing mental health professionals to be able to
treat challenging issues related to sexual and gender
identity, and Lesbian Gay Bisexual Transgender
(LGBT)-related issues.
44. Practicing mental health professionals in UAE are well
trained to treat sensitive issues related to gender and
sexual identity as well as issues related to LGBT
individuals.
45. There is a need to provide a safe environment for
patients with sensitive issues (e.g., gender/sexual
identity, LGBT population, etc.) so that they can
express issues related to them.
46. Issues related to gender/sexual identity, and LGBT

population need to be addressed by mental health
professionals in the UAE.
47. The current level of mental health services provided to

patients with sensitive issues (e.g., gender/sexual
identity, LGBT population, etc.) is satisfactory.
48. Mental health professionals are comfortable in

addressing sensitive issues (e.g., gender/sexual identity,
LGBT-specific issues, etc.).
49. Patients/clients with sensitive issues (e.g.,

gender/sexual identity, LGBT population, etc.) are
usually reluctant to seek psychological help because of
fear of being rejected and/or of possible legal
consequences.
50. The lack of mental health services for individuals with
sensitive issues (e.g. gender/sexual identity, LGBT
population, etc.) marginalizes them and increases the
likelihood of mental health stressors for this population.
Please add additional comments (needs, challenges
and/or suggestions) that you may have regarding
delivery and accessibility of Services to Population

with Sensitive Issues.

Barriers To Delivering and Acc

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Barriers To Delivering and Acc

Uploaded by

Copyright:

Available Formats

BARRIERS TO DELIVERING AND ACCESSING MENTAL HEALTH AND FAMILY

THERAPY SERVICES IN THE UNITED ARAB EMIRATES: PERSPECTIVE OF MENTAL

Dissertation presented to the Faculty of the

California School of Professional Psychology

Alliant International University

In partial fulfillment of the requirements of the degree of

Saad Omar Alkhanbashi

Rajeswari Natrajan-Tyagi, Ph.D., Chairperson

Manijeh Daneshpour, Ph.D.

Sean Davis, Ph.D.

learning and the desire to chase my dreams.

supported me throughout my journey in attaining and completing my doctorate degree in

Consulate General in Los Angeles for their guidance and support.

valuable feedback made my research applicable in the UAE.

would like to thank my brothers (Salim, Mohammed, Abdul-Majeed, Abdul-Rahman, Abdul-

been impossible without my family’s support.

services in the UAE from the perceptive of mental health professionals.

Population, Sampling and Sample Size......................................................................................48

According to World Health organization (WHO) mental health is a state of complete

resources prevent proper treatment to mental health disorders.

psychological wellbeing of the inhabitants of developing nations” (p. 565).

teenagers (age of 13-20) have shown symptoms of depression (Chudhary, 2016b).

Statement of the Problem and Significance of the Study

services in the country and its utilization.

community centers and universities in the United Arab Emirates.

Statement of the Researcher

and enroll in a psychology-related major.

people pursuing education in psychology in general are commonly perceived as having a

immediately changed my major to psychology, and I graduated in 2006.

knowledge needed to make informed mental health policies

professional setting where they provide academic, counseling, or psychiatric-nursing services

practicing within a mental health discipline.

accessing professional mental health services.

Emirates (Kjeilen, 2013).

Arab Emirates, National Bureau of Statistics 2011).

Social Changes That Contributed to the Prevalence of Mental Illnesses

across the country.

Socio-economic changes .The welcoming attitude has encouraged many expatriates to

employment (Al-Darmaki & Sayed, 2009; Al-Darmaki & Yaqeeib, 2015).

catch up to (Lambart, 2008; Thomas, et al., 2015).

(Schvaneveldt et al., 2005).

unemployment among locals (Hamdan, 2009).

psychiatry was stigmatized because it contains psychotropic medications. Culturally, individuals

Dhabi where the economy is becoming more competitive and global.

Family and Social Structure

witnessed the advent and the spread of Islam.

conquered territories (Bobrick, 2012).

modern Arab countries known today (Bobrick, 2012).

maintain or enhance the family status in public.

surrounded by a wall to ensure privacy.

essential to the cohesiveness of the family unit.

family homeostasis is vulnerable to instability.

parents to convey her views to her husband (Barakat, 2007).

more than any country in the Arabian peninsula.

law. Discord between daughters-in-law and mothers-in-law is a frequent source of contention in

relationship evolves to a woman-to-woman friendship.

their expected share to maintain the cohesiveness of the group.

members of the group.

their time and respect (Abudabbeh, 2005).

blame and will carry the guilt and shame.

The Status of Mental Health in the UAE

According to the World Health Organization (WHO, 2011) there is no independent

community mental health care facilities.