A Critical Analysis of the Perceptions and Lived Experiences of Mental Health and Illness in Kuwait

IT‘S A MAD, MAD, MAD, MAD WORLD: A CRITICAL ANALYSIS OF THE PERCEPTIONS AND LIVED EXPERIENCES OF MENTAL HEALTH AND ILLNESS IN KUWAIT.

A Thesis Submitted to the Committee on Graduate Studies in Partial Fulfillment of the Requirements for the Degree of Master of Science in the Faculty of Arts and Science

TRENT UNIVERSITY

Peterborough, Ontario, Canada

Psychology M.Sc. Graduate Program

January 2017

ABSTRACT

It‘s a Mad, Mad, Mad, Mad World: a Critical Analysis Of The Perceptions And Lived

Experiences of Mental Health and Illness In Kuwait.

Neha Khullar

The purpose of this study was to understand the lived experiences of mental health and illness in

Kuwait. Twenty-six participants were interviewed, including mental health professionals, family physicians, and service users. Findings suggest that inequality, oppression, and human rights violations may drive mental health issues in Kuwait. However, rather than addressing these factors, many healthcare providers are endorsing psychological testing and psychiatric medication, which may be resulting in the same iatrogenic (physician-induced) drug dependence that is seen in North America. An analysis of mainstream psychological theory, research and practice is provided, along with a bioethical critique of the World Health Organization‘s efforts to reduce the global ‗burden‘ of mental disorders. This study cuts across disciplinary boundaries and 1) supports medical anthropologists‘ criticisms of the ‗advancement‘ of global mental healthcare; 2) provides participant-driven, community-based alternatives that are specific to

Kuwait; and 3) informs culturally defined notions of ‗care‘ and ‗ethics‘.

Key words: Kuwait, mental healthcare, critical psychology, transcultural psychiatry, qualitative research, critical discourse analysis, interpretive phenomenological analysis, Middle Eastern studies, Islam, cross-cultural psychology, mental health, mental illness, medical anthropology, medical sociology, bioethics.

Acknowledgements

First, I would like to thank my father for supporting me, even during the last years of his life.

Thank you Dad, for always encouraging me to pursue what I found personally and academically meaningful, and, most importantly, for teaching me what true acts of kindness and humility are.

Mom, you‘ve been a beacon of strength during this whole process, and I can‘t thank you enough for walking me through all the highs and lows for the past several years. I will always consider myself so blessed to have a mother like you. Chetan and Jeevan – you‘re both the best, most encouraging older brothers that I could ever ask for. I‘m lucky to have you both in my life.

Kirsten and Faiza – you‘re both like the sisters I never had. Thank you for always being a part of the family, and welcoming me to yours.

Most of the knowledge I cultivated through this research is because of those who participated in the study so a very special thank you goes out to my participants: I am so grateful that you shared your time, knowledge and experiences with me. This project would certainly not have been possible without you. I would also like to thank Chardae Schnabel, Nicholas Hopewell,

Michael Barrett, Kristi Turner, and Amanda Rogers for helping me transcribe my interviews.

You removed much burden off my shoulders by saving me weeks of arduous transcribing.

Salman Alawadi, I would like to express a very sincere appreciation to you for supporting the goals of this project as well as for our enlightening conversations during my time in Kuwait. I look forward to having more discussions with you in the future.

I would also like to thank all my friends, colleagues, roommates, and acquaintances who I met over the years. Rebecca Martin, thank you for making me smile and laugh even when I was at my weakest. Adrian Borlestean, thank you for challenging me on the concepts of scientific

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theory; you helped inspire some very critical thought without even realizing it. Chardae

Schnabel, again, for adding so much fun and colour to my life. Natalie Guttormsson, I don‘t even know how to thank you for just being available as a source of support over the past eight years since we first met. Patrick Murphy, you pushed me towards studying psychology and supporting me when I first arrived Canada, and helped me integrate here. I wouldn‘t have even pursued this if it wasn‘t for you so you certainly deserve an extra special thank you. To all the friends I have not mentioned, you know who you are, and you know I love you, deeply.

I would like to extend my deepest gratitude to all my mentors and professors over the past few years. Dr. Rory Coughlan, I cannot imagine having a more inspiring mentor. You brought me up academically as well as personally, and taught me how to think critically. When I felt I couldn‘t be challenged anymore, you challenged me further and expanded my capacity and appreciation for learning. Thank you for not only being firm with me when I slacked off, but also for showing me so much warmth and patience since I first walked into your office five years ago. You have become more like a parent to me since then and I will always appreciate you for showing me courage that I often fail to see in myself. Dr. Geoff Navara and Dr. Laura Summerfeldt: thank you so much for reading and auditing my work. I have learned a lot from both of you over the past few years while taking your courses and feel so honored that you brought your expertise to this project as part of my thesis committee. Dr. Deborah Kennett and Dr. Elaine Scarfe, thank you for showing me so much kindness since I first enrolled in graduate school: you made me realize that the Trent Psychology and Graduate departments are truly committed to supporting their students. Dr. Michael Chan-Reynolds: my knowledge of and deep appreciation for the history of psychology – which became one of the pillars of this research – began during your lectures, so thank you for imparting your wisdom. Dr. Smith-Chat: your lectures in PSYC-101

inspired me and hundreds of other students. If it wasn‘t for you teaching the course, I may not have continued studying psychology. So thank you for inspiring me so early in my academic career. I would also like to thank all the other Trent University professors and other staff I haven‘t mentioned who supported me over the years – including Dr. David Beresford from the

Biology department, for always being so kind to me. I am also very grateful to the Trent

University, the Department of Psychology, and Graduate Studies for providing funding for my research.

Finally, I would like to thank Dr. Nicholas Scull from the American University of Kuwait and the Fawzia Sultan Rehabilitation Institute and Dr. Elham Hamdan from the Fawzia Sultan

Rehabilitation Institute in Kuwait, without whom this project would not have launched in the first place. You showed me so much personal and professional support since you first welcomed me as part of the team three years ago, and opened up so many opportunities for me. I consider myself so lucky to have met both of you. Thank you for everything, and I look forward to future collaborations with both of you.

Table of Contents

Abstract ...... ii

Acknowledgements ...... iii

List of Figures ...... xii

List of Appendices ...... xiii

Chapter I. The Historical Foundations of Psychology in North America...... 1

Psychology‘s Premises ...... 3

Kant‘s criticisms...... 4

Limiting intentionality and agency...... 5

The Rise of Experimentalism ...... 6

A feminist critique of objectivity...... 8

A misguided identity ...... 9

Psychology: The New American Hero...... 10

Introducing dualism and ―mind-stuff‖ to Psychology...... 11

A Brief History of ―Social Control‖ ...... 13

The Role of War ...... 14

Controlling the aggregate...... 15

Military intelligence and the cult of ―maximum efficiency‖...... 17

Culture, Ideology, and Capital ...... 20

How Cognitivism and Humanism retained the Stimulus Response Model ...... 22

A Marxist critique of Humanistic Psychology...... 23

Current School of Thought ...... 25

Chapter II. Mental Healthcare and the Classification of Insanity ...... 27

The Roots of Insanity ...... 27

An ancient portrait of humanity and medieval concepts of madness...... 28

The Origins of Mental Health Care ...... 31

The birth of Psychiatry...... 33

Constructing the DSM ...... 44

The DSM-I: psychiatrists mark their territory...... 44

The DSM-II: replacing the straightjacket with pharmacology...... 45

A critical reflection of anti-psychiatry movements...... 47

DSM-III: the tautology of disease-centered Psychiatry...... 49

DSM-IV: meta-analysis or cultural homogeny? ...... 51

DSM-5: everyone is mad! ...... 55

Chapter III. The International Politics of Mental Health Care ...... 59

The Assumption that we are Treating Brain Disorders ...... 61

Predominant themes in research and rehabilitation...... 64

Schizophrenia: A Social and (Environ)mental Etiology ...... 66

Changing the Phenomenology of Self-Starvation in China ...... 70

Parachute Therapists in Disaster Zones ...... 76

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Recruiting mental health advocates...... 77

Glorified martyrdom...... 83

The Bioethics of Transnational Psychopharmacotherapy ...... 85

Modernization: changing the meaning of well-being...... 90

Illness negotiation as a social and political process...... 98

Chapter IV. History, Culture, and Mental Healthcare in Kuwait ...... 109

Kuwait‘s Golden Era and Islamic Resistance ...... 112

A Brief History of Violence ...... 115

The Intersection between Religion and Law in Kuwait ...... 118

Kuwaiti Culture ...... 123

Introducing Mental Healthcare to Kuwait ...... 126

The Current Mental Health System in Kuwait ...... 130

Chapter V. Methods: Using Critical Theory to Inform Qualitative Research ...... 137

The Cartesian Mind ...... 137

Critical Psychology: Phenomenology and Praxis ...... 145

Reconceptualising ‗care‘...... 151

Dialectic method...... 153

Purpose ...... 156

Data Collection ...... 157

Participants...... 159

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Semi-structured interviews...... 161

Data Analysis ...... 163

Phase 1: Interpretive Phenomenological Analysis...... 164

Phase 2: Critical Discourse Analysis...... 168

Chapter VI. Results: Discourses on Oppression, Inequality, and Resistance in Kuwait ...... 172

Perceptions about Kuwait...... 172

1. Mental health issues are presented and need to be treated differently in Kuwait as compared

to how they are in the West ...... 178

1.1. Families and therapy...... 179

1.2. Emotional distress and somatization...... 181

1.3. The severity of mental illness in Kuwait compared to the West ...... 183

2. Inequality drives mental health issues in Kuwait ...... 186

2.1. Patriarchy and inequality ...... 187

2.2. Foreign workers, oppression, and abuse ...... 196

2.3. Psychosocial consequences of industrialization for high-income families...... 199

2.4. High status and complacency towards human rights violations in Kuwait ...... 204

3. Ideological and cultural conflicts affect mental health and the practice of mental healthcare

in Kuwait ...... 205

3.1. Intergenerational conflicts, materialistic and post-materialistic values ...... 206

3.2. Materialistic and post-materialistic values versus Kuwaiti and Western values ...... 210

3.3. Enhancing cultural integration in Kuwait ...... 214

3.4. Mental health professionals‘ ideological perspectives...... 221

3.5. How medical discourse transforms indigenous perceptions of health and illness...... 232

4. Methods of resistance are often misunderstood by mental health professionals in Kuwait 240

4.1. Resistance to mental healthcare is recast as stigma ...... 240

4.2. Resistance to authority is recast as deviance or diagnosed as a mental disorder...... 243

4.3. Fear of punishment and social exclusion ...... 246

4.4. Kuwait may be on the brink of social reform...... 249

Chapter VII. Discussion: Marketing Mental Illness in Kuwait? A Critical Analysis of Global

Medical Discourse in Action ...... 257

Kuwait: a Cultural Paradox ...... 258

Westernization or Modernization? Understanding Dialectical Change and Mental Illness in

Kuwait...... 260

The effects of dialectical change on mental health in Kuwait...... 268

Negotiating agency in the wake of modernization...... 271

Neoliberalism, Inequality and Human Rights Violations in Kuwait: Mental Illness or Social

Defeat? ...... 274

Social fragmentation...... 275

The Kafala system...... 279

Immigration, racism, and social defeat...... 282

Drugs À La Carte: Silencing the Resistance of Oppressed Groups in Kuwait? ...... 288

Socially Marketing Mental Illness in Kuwait ...... 293

Bioethics in Kuwait ...... 296

Chapter VIII. From Clinical to Critical Practice: Reconceptualising the Role of Mental

Healthcare to Promote Public Discourse on Health and Social Justice in Kuwait ...... 299

Is Mental Healthcare Equipped to Resolve ―Intergenerational Conflict‖? ...... 301

Ethical Service Delivery...... 304

A critical and cultural take on ethics...... 306

Ancient Muslim Caregiving Practices...... 311

De-stigmatizing Mental Healthcare and Mental Illness in Kuwait ...... 313

Bioethical Risks associated with De-stigmatization, and how to mitigate them...... 315

Iatrogenesis and the ―worried well‖...... 317

Primary care taking over psychiatry? ...... 320

Diagnostic Deflation...... 322

Counteracting drug company propaganda...... 324

Conclusion: Increasing the Momentum of Social and Political Reform in Kuwait ...... 326

Reflexivity...... 332

References ...... 342

Appendices ...... 369

List of Figures

Figures Description

1 A Model for Critical Psychology…………………………….……….149

2 A Model for Dialectical Change……………………………………...154

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List of Appendices

Appendix Description

A Information and Consent Form: Mental Health Professionals……….369

B Information and Consent Form: Clients and Patients………………...371

C Information and Consent Form: Kuwait Community Members……..373

D Interview Protocol: Mental Health Professionals…………………….375

E Interview Protocol: Clients and Patients……………………………..377

F Interview Protocol: Kuwait Community Members…………………..379

G Feedback Letter: Mental Health Professionals………………………381

H Feedback Letter: Clients and Patients……………………………….382

I Feedback Letter: Kuwait Community Members……………………383

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Chapter I. The Historical Foundations of Psychology in North America

Psychology has a rich and complicated past. Any astute scholar in the social sciences understands that tracing its development in its entirety is near to impossible and would require a lifetime of painstaking dedication. I have thus focussed on aspects of its history that I find most relevant to support my position that psychology, since its inception, continues to be in a state of moral, ontological, and epistemological crisis and denying this only acts to further limit the scope of the discipline. I will focus on psychology‘s history in the context of the major philosophical, socio-political and cultural changes that took place in the Western world during the past century. Special attention will be given to North American Psychology since it is the most globally dominant ideological framework within which most (i.e., ―mainstream‖) psychologists, psychiatrists, and consumers of psychological knowledge appear to think, feel, and behave. Throughout the course of this thesis, I present and also echo some of the contemporary critiques of the mental health enterprise that have been published by prominent psychiatrists (e.g., Allen Frances), psychologists (e.g., Gary Greenberg), medical anthropologists

(e.g., Arthur Kleinman) as well as journalists (e.g., Ethan Watters). They collectively argue what many academics – from Michel Foucault to Kurt Danziger – have argued since the modern inception of mental healthcare: that the mental health industry has largely over-estimated and glamorized its humanitarian potential. This is largely owing to the theory, research, practice, and social marketing of mental healthcare in ways that primarily benefit private corporations (e.g., pharmaceutical drug manufacturers and marketers) rather than public communities.

Some of the critiques of clinical psychology and psychiatry are demonizing, and one goal of this thesis is to demonstrate that clinical practice may not be as monolithic as it may appear.

This is because mental health professionals‘ ideological perspectives – grounded in their academic and professional trajectories that shape their own narratives of self, other, and society – can be rather fluid and capable of transforming how psychology and psychiatry are practiced around the world. In this way, mental healthcare shares the same paradox of ―science‖ and

―religion‖: it can be both the toxin that unwittingly perpetuates oppression and exploitation, as well as the antidote that cures it. (These different outcomes of psychological theory require a discussion about the separation between ―theory‖ and ―practice‖ – i.e., the ―praxis‖ – of mental healthcare, which is addressed in Chapter V).

The way the history of psychology is presented is largely influenced by how the knowledge contributed by the field is organized (Danzinger, 1994). During the past four decades

– with the exception of some texts (e.g., Hothersall, 1984; Leary, 1994; Schultz, 1969) – the vast majority of academic sources from the Western world have taught scholars about the prominent psychologists and theories from late 19th century structuralism to late 20th century humanism when discussing its history (e.g., Atkinson, 1996; Hergenhahn & Henley, 2013; Nolen-

Hoeksema & Rector, 2004; Weiten, 2007; Wertheimer, 2012). However, if we see psychology as an aggregate of these prominent figures, theories and findings, psychological research and practice will merely be grounded in its prominent figures, theories and findings (Danzinger,

1994). This description is a convenient, albeit a powerful disguise for the political constraints within which the discipline was established and continues to operate today.

To understand modern psychology‘s inception, we need to turn to its philosophical foundations (dating back to Plato and Descartes) as well as some historical analyses of the discipline from the last century since psychology (and the mental health industry at large), as we know it today, is a consequence of the modern economic and industrial complex – or

modernization (e.g., Danzinger, 1994;1997; Gergen, 2001; Gökmenoğlu, Eret, & Kiraz, 2010;

Reicher, 1996; Scull, 1989). And if we are, to any meaningful extent, use a critical eye to modify the direction and scope of psychological research and practice (much like a psychotherapist would trace his or her clients‘ childhood experiences), we need to evaluate the authoritative and administrative practices that governed psychology‘s evolutionary trajectory using not only a postmodern lens (e.g., Gergen, 2001), but also philosophical, sociological, anthropological, and transnational perspectives (Applbaum, 1998; 2004; 2006; Harrist & Richardson, 2014; Kleinman

& van der Geest, 2009;Young, 2008). This will also allow us to systemically analyze how social and cultural forces continue to shape psychology‘s implications more globally, in postmodern times. This is also where some of the major ―revolutions‖ (or shifts in schools of thought) in psychology will be analyzed in light of the arguments put forth by various critical scholars to demonstrate that contemporary psychology is, in many cases, a mere reiteration of methodological (i.e. Watsonian) behaviourism. As we will see in Chapters II and III, this can strip away the ‗care‘ in mental healthcare (Coughlan, 2006; Kleinman & van der Geest, 2009).

Psychology‟s Premises

Psychology was largely constructed as a product of two separate but highly integrated premises. As a fusion of ancient philosophy and contemporary natural science, its goal to understand ―humanity‖ was contingent on adopting methods that were considered scientifically valid (Danzinger, 1994). The appearance of validity became an important driving force for developing an epistemology that first appeared to concern the individual, but was later refined through a succession of conflicts between true experimental studies on individuals and statistical overviews of population characteristics (see Controlling the aggregate, p. 13). The first premise that has largely governed psychology is that each psychological construct or concept (e.g.,

intelligence or trauma) naturally corresponds to one hidden truth that is ―out there‖, which is only accessible by qualified professionals who can understand it through experimental research

(Danzinger, 1994; 1997; Fox, Prilleltensky & Austin, 2009; Hesse-Biber & Leavy, 2011; Parker,

2005; Parker & Spears, 1996; Willig, 2013). Following this positivistic position, the second premise is that humans are passive recipients of their environments (rather than agents), governed by a set of natural laws that will predict their behaviour. As much as this position is associated with the stimulus-response model of mid-20th century behaviourism (Ulman, 1996), it can be traced back to the first psychological school of structuralism during the late 19th century.

Later schools of functionalism, behaviourism, cognitivism and humanism largely were, and sometimes continue to be, grounded in this stimulus-response paradigm (Boring, 1950; James,

1890; R. Coughlan, personal communication, March, 2014; Schultz, 1969). Regardless of the number of criticisms that applied psychology received even prior to the formal establishment of the discipline and regardless, also, of many mental health professionals‘ (including leftist social workers) efforts in advocating for political action with oppressed and marginalized groups, more mainstream psychologists often viewed psychology as a natural science (rather than a domain within the humanities) under the direct governance of the state.

Kant‟s criticisms. To understand how psychology was criticized for its attempts to be a

―natural science‖, grounded in hypothetico-deductive (i.e. top down, theory driven) research, I turned to what was, at the time, a largely ignored warning and criticism to those trying to understand the human psyche (Kant & Woods, 1781/2001; Danzinger, 1994). Despite Kant‘s dry and often cumbersome style of writing (for which he went relatively unheard within the psychological community), he argued that the human psyche will always be resistant to quantification. Unlike the mechanics of physical planetary changes in Newtonian science, the

psyche (or what Kant referred to as the ―internal sense‖) could not be compartmentalized in a way that would allow investigators to draw meaningful, mathematical conclusions (Danzinger,

1994, p. 20). By ignoring this argument, however, much of psychological knowledge has come to be grounded in a priori judgements that are viewed as principles of the human condition (Kant

& Woods, 1781/2001, p. 34). In contemporary psychology, these a priori judgements take the form of preconceived theories that are not actually grounded in empirical evidence, and the principals take the form of ‗natural‘ laws of human behaviour.

Limiting intentionality and agency. Owing to the tendency to view synthetic, preconceived theories as natural laws, more ―critical‖ psychologists argue that many mainstream psychologists have developed a ―God‘s eye view‖ to their research and practice (e.g., Willig,

2013, p. 6). Therefore in a laboratory setting a subject is only capable of acting within the confines of this top-down, theory-driven context. In other words, by viewing the individual through a stimulus-response lens, the subject is isolated and abstracted from his or her natural world, and thus treated as a passive responder in the research setting. This limits the intentionality (knowing that our ideologies, context, and values are capable of directing us to our environment with the goal of acting upon it) of the subject, and, as a result, strips them of their agency (knowledge that one is capable of modifying their environment to control their personal experiences) (Banchetti-Robino, 2004; Coughlan, 2006; Pippin, 1991; Tolman, 1994). Within the stimulus-response paradigm, there is little room for participant intentionality and thus agency and the power differential that sometimes manifests within the research relationship can resemble some of the ―bourgeois‖ relationships in industrialized economies; i.e., it can become analogous to that of the master (researcher) and the puppet (subject).

Although the stimulus-response paradigm has permeated multiple schools of psychology, it is most closely associated with behaviourism. To the behaviourists, anything that fell outside the narrow parameters of a stimulus, response, or reinforcement, was considered non-objective, non-pragmatic, and thus non-scientific. In short, as Tolman (2009) noted, subjectivity – which fell outside these parameters – was considered to be an ―epiphenomenon‖, deemed less worthy of psychology‘s attention. As Tolman (2009) quite succinctly wrote, ―all knowledge was relevant; it was really a matter of the parties to whom it was relevant‖ (p. 151). The mechanisms of the stimulus-response paradigm developed from a need to control urban society, therefore the state found tremendous use for it as it left no room to consider the intersubjective experiences and needs of the wider public. This is, as some critical thinkers (e.g., Danziger, 1994; Reicher,

1996) argue, analogous to the hierarchical arrangements of a bourgeois capitalist society (see

Controlling the Aggregate for a more in-depth discussion on behaviourism‘s relationship to capitalism).

The Rise of Experimentalism

Wundt has rightfully been reputed as the prominent founding father of Psychology for establishing Psychology‘s first laboratory in Leipzig in 1879 and distinguishing the discipline from other sciences (Smith, 1982; Titchener, 1921; Vygotsky, 1980). Arguably, his three most influential pupils were Edward B. Titchener, James M. Cattell, and, although known to a lesser extent, Hugo Münsterberg. Most of Wundt‘s teachings were brought to America by his disciples who formed their own scientific communities of experimenters in Germany, and later in the

United States (Danzinger, 1994). His work was overall misrepresented, and in some cases, mistranslated, in North America (Smith, 1982). For instance, contrary to Titchener‘s (1921) translations of Wundt‘s work, Wundt emphasized that experimentalism could not significantly

define the field of Psychology (Smith, 1982). In fact, Wundt made a sharp distinction between higher and lower mental processes, where intelligence, emotional disposition, and other elements of consciousness fell within the domain of higher mental processes, while physiological or sensory (e.g. motor and visual) responses fell within the domain of lower mental processes

(Vygotsky, 1980). Wundt argued that natural science methodologies (Naturwissenschaften) could only be used to study lower mental processes, while social and anthropological methods

(Geisteswissenschaften) were necessary to understand the complex characteristics of the subjective experience of consciousness. This included nearly everything we understand today to be the subject of psychological investigation apart from basic operations of sensation.

Titchener‘s mistranslation of Wundt‘s work only served to propagate and promote the school of Structuralism which was rooted in the notion that the mind could be broken down into separate, measurable components (Blumenthal, 1998). Additionally, Cattell‘s research and involvement in the eugenics movement along with the groundless public attacks of Wundt further distorted scholars‘ understandings of Psychology and spawned several critical attacks of

Wundt‘s work (Münsterberg‘s 1898a; 1898b; Sokal, 1980). For example, researchers such as

Cattell measured intelligence as a simple mental construct through memory tests and response times (Godin, 2007); this contradicted Wundt‘s view on higher mental processes and the methods appropriate to their definition and investigation.

The culture of experimentalism that developed as a byproduct of Wundt‘s laboratory was not in line with that of the natural sciences, however (Danzinger, 1994). In a chemical laboratory, for instance, the object of investigation (e.g. a chemical compound in a petri dish) is not socially susceptible to the influence of the researcher unlike the subject (i.e. research participant) in a psychological laboratory is. What is equally important is the social impact of the

research subject on the researcher and the investigation itself (Harraway, 1988). However, by abandoning Wundt‘s original proposition, many first generation Wundtian psychologists and their academic progenies took the same stance towards the human psyche that natural scientists took towards objects, and, as we will see below, some elite males took towards life in general.

A feminist critique of objectivity. Although some radical feminists such as Harraway

(1988) argued that this God trick is self-imposed within a ―male-dominated discipline‖, we can see that is only partly true. The God‘s view was also owing to the economic reinforcements psychologists received from the state; by associating ―masculinity‖ with ―objectivity‖, psychologists (who were all predominantly male) enacted the idealized image that was created for them by what some feminists refer to as the ―bourgeois‖ male elites. These male psychologists therefore became assimilated into a community that reinforced the ideology of objectivism in the human sciences. Ironically, despite Psychology‘s attempt to be a natural science, the notion of objectivity when studying the psyche is not an ontologically natural stance, but an ideological one, in which the researcher removes himself from the research situation (R. Coughlan, personal communication, March, 2014). This is clearly seen when

Wundt‘s disciples abandoned Wundt‘s notion of researcher introspection (which is, in and of itself, a subjective experience) (Danzinger, 1994). By denying that a researcher‘s personal experiences and perceptions can shape the research situation, mainstream psychologists, much like mainstream economists, generally operated under the Platonian notion that they were

‗separate‘ from the natural world and claimed, for themselves alone, the ability to find

―objective‖ reality and to represent it mathematically (Sedlacek, 2011). Since introspection could not yield to a mathematical equation the same way chemical reactions could in a lab,

psychologists after Wundt generally abandoned it in the hopes of being accepted within the scientific community (Danzinger, 1994).

A misguided identity. Münsterberg was initially highly critical of studying conscious elements through an experimentalist lens. When he became the president of the American

Psychological Association (APA) and a professor at Harvard University under William James‘ recommendation (Schultz, 1969), Münsterberg publicly attacked ‗Wundtian‘ psychologists for relying too heavily on experimental methods to study the mind. He quite aptly argued that

Psychology (especially in educational and institutional settings) was turning into a discipline of deception, leaving Psychology in a state of moral crisis:

This rush toward experimental psychology is an absurdity…There is no

measurement of psychical facts [and] the figures will deceive you… It was a

misled curiosity [among psychologists] to think that a quantitative psychology

would be better than a qualitative one. (Munsterberg, 1898a, p. 166).

Münsterberg started his career as one of the first critical psychologists, but experimental methods garnered the reins of psychology since any psychologist who was not doing experimental work had very little chance of professional success in a culture where the natural science methodologies being utilized were conflated with the essential aspects of a scientific stance, per se (Münsterberg, 1903;1908). Owing to Munsterberg‘s public criticisms, he was accused of being a German spy during World War I and was shunned within the psychological community in the United States (Doherty, 1996). However, when he began his more experimental work on eyewitness memory, industrial efficiency and advertising - i.e. contradicting his original criticism of Psychology – he suddenly became of great value to the state and later became known as the father of both modern Forensic Psychology and Industrial

and Organizational Psychology (Benjamin, 2006; Munsterberg, 1908; 1914), both of which sought the knowledge products that increased the ability to predict and control ordinary people‘s behaviour. In other words, Münsterberg adopted what Reicher (1996) characterized as a Faustian contract, whereby he bought his own autonomy and agency as an elite academic at the cost of the agency of those he studied (Reicher, 1996).

Despite Münsterberg‘s (1908) initial criticism and research that debunked some of the states‘ legal practices (e.g., by demonstrating the fallaciousness of eyewitness memory), the individual further became an object of science, open to more scrutiny, experimentation and prediction by ―qualified‖ psychologists. Combined with Cattell‘s and Titchener‘s misrepresentations of Wundt‘s paradigm in Germany, Psychology became centered on this philosophy and became a system of surveillance, prediction, manipulation, and control in North

America.

Psychology: The New American Hero.

Around the turn of the 20th century, while Münsterberg was in and out of the limelight,

Psychology became a fusion of German experimentalism and Darwinian naturalism (Boring,

1950; Schultz, 1969). Despite the large number of scholars who trained with Wundt in Germany to later pursue careers in the United States, American psychology was far more Galtonian

(Schultz, 1969). For instance, the principles of ―natural selection‖ and ―survival of the fittest‖ – where academic and professional success, as well as the overall survival of the discipline – were contingent upon how well Psychologists adapted to spirit of ―maximum efficiency‖ (Callahan,

1962; Fink, 1963). Although he was not a Psychologist, William James applied the theory of adaptation to consciousness, where its sole purpose was to help a person adapt to his or her environment. This became known as the school of Functionalism (Schultz, 1969).

Similar to most great thinkers and philosophers, James was epistemologically conflicted.

Regardless of how popular he became, it is important to comment on the paradoxes that existed in his writing (James, 1907; 1909a). For instance, similar to Kant, James disagreed with the structuralist notion that consciousness could be divided into discrete elements and coined the term ―stream of consciousness‖ to describe how the mind exists as a continuous flow of experiences, which, when reduced to its individual components, becomes decontextualized and meaningless (Schultz, 1969). The minutiae of the experimentalist method (even when James pursued a career in medicine) irritated him and he felt that there was no place for it in

Psychology (James, 1890).

James became highly influential within the disciple for three reasons (Shultz, 1969).

First, the charisma with which he wrote floored the majority of scholars and elites who read his work; second, he became an underdog in Psychology for turning his back against structuralism as a radical empiricist, which was enough to capture the attention of the psychological community; and third, he provided an alternative, ―functional‖ way of understanding the mind.

Principles of Psychology (James, 1890) was in and of itself a major event in the history of modern Psychology (Schultz, 1969). Ironically, despite his irritation with the experimentalist method, James‘ Psychology was treated as a natural science as he applied the theory of adaptation to human consciousness. Similar to structuralism, functionalism became centered on the idea that humans are merely passive recipients of their environments and his theory that consciousness is functional and capable of adapting to changing environments became conflated with the goal to rapidly increase production and profit in the wake of modernization.

Introducing dualism and “mind-stuff” to Psychology. Plato, and later Descartes (in

Meditationes de prima philosophia, 1641/1842), introduced the concept of soul-body dualism to

philosophy which eventually plagued Western psychological thought. By the 19th century, consciousness replaced the concept of the soul; dualism was presented in the form of knower and known, consciousness and content, objective and subjective, and sensation and perception

(Taylor & Wozniak, 1996). It is important to highlight what Costall (1995) noted: that

―Psychology, as a modern academic discipline, did not create these dualisms but was created by them‖ (p. 467). Prior to Wundt‘s establishment of his laboratory, the majority of psychology articles and monographs were published in the journal Mind. One of the earliest renditions of contemporary psychological dualism was articulated in Clifford‘s (1878) term, mind-stuff in an attempt to explain the metaphysics of consciousness. To Clifford – who was both a mathematician and philosopher – the ―stuff‖ was merely a coagulation of atoms (i.e. the brain) in which consciousness was developed. Essentially, the birth of experimental cognitivism began before psychology was even established as a discipline. In A Pluralistic Universe, James (1909b) criticized the dualism that was beginning to appear in psychology and instead argued for a monism in an attempt to transcend the dualism of ‗mind-stuff‘. By abandoning the notion of consciousness as an entity separate from external experience, he concluded that all that can exist in the world of Psychology is subjective experience where there is no internal-external separation

(Lamberth, 1999; Taylor & Wozniak, 1996). This, as we will see in Chapter V, parallels the theories put forth by phenomenologists such as Husserl in the early 20th century (Banchetti-

Robino, 2004).

However, despite being somewhat of a progressive figure in Psychology, James‘ philosophies were applied to the natural scientific methodology. This can be seen in the application of his writings that spurred the ideology of pragmatism in North America. Although

James dedicated his book Pragmatism to the concept, the fundamental core of Jamesian

pragmatism is that the validity of a theory or idea can only be measured by its practical utility

(James, 1907). However, pragmatism was not considered to be a subjective estimation as James had intended; ultimately, what was deemed practical (objective and ideal) or impractical

(subjective and meaningless) was in the direct control of the state. The application of a functionalistic (or Jamesian) psychology was a milestone in the evolution of the discipline.

Adapting to a fast-paced environment was a necessary requirement during the industrial revolution since the American economy depended on labour efficiency for the purpose of maximizing capital. Essentially, any means that could achieve this end were considered pragmatic. No other discipline could survey, predict, manipulate and control the labour force in an industrialized society (Marx & Engels, 1965), and later, civilians in their own homes through pro-American, pro-War propaganda (Danzinger, 1994).

The vast majority of psychologists thus internalized and happily played the role of the new American hero that was created for them; by promising the state that they could discover methods that would categorize, delineate, and excavate the mind for the purpose of industrial efficiency – which the state deemed as ―socially relevant‖ – they received governmental appraisal and funding (Danzinger, 1994; Reicher, 1996). What the state claimed to be socially relevant, however, was merely a disguise for creating the necessarily tools to realize their agenda for social control, which is explained below.

A Brief History of “Social Control”

Rothman (1985) conducted a historiographical analysis on the concept of social control to understand how cultural ideologies in Europe and North America influenced historians‘ and sociologists‘ use of the term. Although the contemporary definition of social control is rooted in coercion and oppression, sociologists after World War I (e.g., Mead, 1925; Rothman, 1985)

defined social control in terms of harmony, unity, and cooperation. Rather than associating social control to the self-interests or regulatory powers of the state, social control fell within smaller domains – or ―institutions‖ (Mead, 1925, p. 275) – such as the family and the work-place. To this end, high social control was associated with a stronger ability to assume the attitudes of individuals in their immediate social circle. Although this notion of social control appears to be limited to the period between World War I and World War II, Russon (2003) recently reiterated

Mead‘s philosophy; what Mead called social control, is what Russon referred to as habituation into the intersubjective, or suprafamilial world to achieve harmony. Both Mead‘s (1925) and

Russon‘s (2003) philosophies are ideal, however they were based on the premise that the state is acting within the best interests of society. To further understand why social control was associated with harmony as opposed to oppression, we need to understand the intentions of the state following World War I.

The Role of War

It was no coincidence that the major transitions that took place within psychological research and theory occurred in the United States during times of war, when it was in the best interests of the government to regulate large groups of people. The Espionage Act of 1917 is a clear-cut example of how the United States regulated research through the control of propaganda.

The act served to imprison, or at the very least, censor the work of those who showed any sign of resistance towards the United States‘ involvement in the war. Owing to their Freedom of Speech act, the United States ―had no laws adequate to deal with the insidious methods of internal hostile activities... and needed legislation to suppress disloyal activities‖ (O‘Brian, 1952;

Woodrow Wilson‘s Third Annual Speech, as cited in Stone, 2003). Therefore, by passing the

Espionage Act, the U.S. government was able to elicit public fear and thus control propaganda.

All published social and psychological research was also constrained by the same laws and regulations.

Controlling the aggregate. There were two epistemological positions available to

Psychology during its Structural and Functional phases (Danzinger, 1994). The first was that of experimentalism which was typically utilized by the natural sciences and the second pertained to simple epidemiological, or prevalence studies that resembled census taking. Although both methodologies are quantitative in nature and used in conjunction today, they were vast differences in how they were used prior to the behaviourist revolution. Experimental psychologists esteemed themselves for using laboratory science to collect data that was considered to be unambiguous and highly internally consistent and valid.

This lure of appearing ―scientific‖ could not exist for psychologists such as Cattell who were interested in population studies (Sokal, 1980). Therefore, to compensate for their lack of credibility, psychologists turned to physicists and mathematicians such as Quetelet who introduced statistics to the social sciences (Beirne, 1987). This pushed psychologists to multiply the number of study participants in their studies (Danzinger, 1994). Additionally, psychologists such as Thorndike began focussing on aggregate data under the direct supervision of educational administrators, resulting in the development of the Journal of Educational Psychology

(Danzinger, 1994), which helped lay the foundation for Behaviourism.

This journal began publishing large scale aptitude tests on children, the results of which were used as evidence that psychologists could help military administrators who provided substantial funding for psychological research. For instance, results from questionnaires and personality tests on children (e.g. by G Stanley Hall and Francis Galton) were used as evidence

that the same procedures could be used in the military (Danzinger, 1994). These studies provided the military with information about the personality traits that needed to be reinforced for making people engage in acts that were inhumane and in times of peace considered immoral. Therefore, the primary consumers and beneficiaries of psychological research became those in authority as opposed to the individuals participating in the research and therefore the populations that research findings were intended to control (Danzinger, 1994).

A discipline that was initially developed to understand the human psyche for the purpose of easing human suffering quickly turned into a force that was used to reduce the human condition into an abstract set of laws and principles. The state was the sole beneficiary of these principles as it gave them more power to regulate the population. This became pivotal during

World War II, when Behaviourism and industrial advertising saw their most rapid growth. Since there was so much emphasis on studying the mind, which was considered to be too intangible for true experimentalists, psychologists needed to abandon it, ―through systematic observation and experimentation [to discover] the laws and principles which underlie man‘s reactions‖ (Watson,

1919, p. 21). Watson further reduced Psychology as a discipline where the mind and consciousness did not exist; this became known as methodological behaviourism (aka logical positivism). This differed from radical behaviourism which reintroduced the mind into

Psychology (Ulman, 1996). While Skinner and a very small minority of radical behaviourists attempted to abandon the Watsonian position, it came to dominate American Psychology. It was the perfect psychology as it was, even across species, universal and both quantitative as well as experimental (Tolman, 2009). For this reason, Behaviourism ―conquered itself to death [and became] a truism‖ (Bergman, 1956, p. 270). This is seen most explicitly when we examine the discipline‘s involvement in war.

Military intelligence and the cult of “maximum efficiency”. Wars – regardless of their impact on a country‘s economy – generally lead to urgent demands for technological advancement. After World War I, the United States military power and economy flourished

(Gökmenoğlu, Eret, & Kiraz, 2010). With adequate financial resources and the high demand to train military personnel, educational (i.e. behavioural) psychology, industrial advertising, and later, cognitive psychology, became natural allies with the United States military industrial complex. Substantial manpower was required to operate newly developed wireless communication systems, aircrafts, and tanks; therefore, behavioural techniques including

―repetition, drills, practices, punishment, discipline, physical conditioning, and reinforcement‖ became commonplace in the military (Lafferty, 2007, as cited in Gökmenoğlu, Eret, & Kiraz,

2010, p. 295). In fact, even Skinner (who, as we saw earlier, tried to redefine behaviourism) inadvertently supported the use of a Watsonian Psychology:

Science is steadily increasing our power to influence, change, mould – in a word,

control – human behavior. It has extended our "understanding" (whatever that may

be) so that we deal more successfully with people in nonscientific ways, but it has

also identified conditions or variables which can be used to predict and control

behavior in a new, and increasingly rigorous, technology. (Rogers & Skinner, 1956,

p. 1057)

One of the most common training components was the intentional manipulation of elementary and secondary school settings for the purpose of providing desired behavioural changes (Gökmenoğlu, Eret, & Kiraz, 2010). According to Fink (1963), many of these instructional guides for teachers were based on John Bobbit‘s 1924 best seller: New Technique of

Curriculum Making‖. It is also worth mentioning that Bobbit was an avid supporter and member of the Efficiency Movement as a representative of the Efficiency Minded Thinkers in the early 20th century (Fink, 1963). These thinkers were, in many ways, the driving force behind turning the education system into a meritocracy, whereby merit was based on how those in management positions (who were considered to be ―smarter‖) defined intellectual efficiency (Holt, 1994).

Some scholars in the fields of philosophy and education have gone to the extent of calling

―maximum efficiency‖ a bourgeois capitalist cult (e.g. Callahan, 1962; Fink, 1963; Holt, 1994;

Lee, 2003). For instance, Callahan (1962) demonstrated that the superintendent in schools played the role of the educational leader, the business executive, as well as an applied social scientist.

Educational leaders became business leaders who were interested in making schools more reputable within the market economy by using psychological techniques to systematically elicit desired behavioural changes (Gökmenoğlu, Eret, & Kiraz, 2010). For instance, the Military and

Industrial Approach (Mager, Gagne & Brigg, 1962), Nine Steps of Instruction, Hierarchical learning (Gagne, 1965), and Stating Behavioural Objectives for Classroom Instruction

(Gronlund, 1970) were all reiterations of Watson‘s (1928) notorious book, Psychological Care of

Infant and Child. Within this paradigm, the ideal (i.e., good, and moral) individual is essentially a machine who passively responds to the demands of authority, while maintaining an aura of happiness and high efficiency:

[The individual] never cries… who loses himself in work and play – who quickly learns to overcome the small difficulties in his environment… who puts on such habits of politeness and neatness and cleanliness… without fighting incessantly for notice… [and] asks no questions for conscience sake. (Watson, 1928, p. 9-10)

By using a Watsonian psychology for military intelligence, administrators were able to reinforce and therefore maintain desired behavioural changes that ultimately shaped America to be a meritocratic, competitive, warrior nation. By turning a blind eye to their role in aiding key military stakeholders to control the aggregate, many psychologists, in practice, have ultimately turned their backs on the philosophical foundations that are supposed to govern all psychological research and practice: to understand humans‘ lived experiences with the goal of easing human suffering (Danzinger, 1997; Dingfelder, 2003). We can argue that if psychologists do not view the elite industrial complex and many of the societal ‗reforms‘ (e.g., intelligence and efficiency) that it spawned as potentially problematic to humanity at large, they are operating under the false assumption that they are serving ―the greater good‖ when they are in fact serving the interests of the bourgeois administrators who benefit from a disempowered society (or at the very least, are being exploited by them). Reicher (1996) reminds us of the three classes of academics that were characterized by a leader of the National Education Crisis Committee (NECC) when discussing apartheid in South Africa: there are those who advocate for oppression, those who verbally oppose it but nonetheless benefit from it, and those who actively participate in the struggle for liberation. ―Were psychologists inclined to become activists, academic institutions, professional institutions and state institutions would all be ranged against them‖ (Reicher, 1996, p. 232), therefore psychologists can generally say what they like, as long as they do what they are told. In other words, Psychology, as a discipline, is largely operating without intentionality and agency and, just like the individuals it can seek to understand (control), is the victim of a false consciousness. This can be further understood when we begin to draw parallels between

Marxism and critical psychology.

Culture, Ideology, and Capital

It is clear from their writings in The German Ideology that Marx and Engels (1965) were at least a century ahead of their time when their theories are explored in light of the 20th century

―proletariat‖ in the United States. Engels‘ research on the working class in England in the mid-

19th century propelled him to critically examine their oppressive working conditions, and assert that ―they must strive to secure a better, more human position… And this they cannot do without attacking the interest of the bourgeoisie‖ (Engels, 1969, p. 239), as ―the ruling ideas of any era are the ideas of the ruling class‖ (Marx & Engels, 1965, p. 60). In other words, the consciousness of the proletariat was a combination of class consciousness and bourgeois ideologies (Parker &

Spears, 1996). This propelled them to develop their theories of commodity fetishism and false consciousness, as explained below.

As part of the industrial revolution, the United States experienced an upsurge in both human and commodity capital; in light of this new ―American spirit‖ (which we will see later, is not all that American), Marx‘s and Engels‘ (1965) notion of commodity fetishism became a natural adjunct to a broader critical analysis of a capitalistic economy. Here, there are no differences between how workers, objects, and psychological knowledge products are related and defined; i.e. people are ―thingified‖ (p.37). This was seen, for example, in research on intelligence, mental efficiency, response times, and general mental ability (e.g., see Thorndike,

1986; Godin, 2007; Munsterberg, 1998; Islam & Zyphur, 2001). The purpose of these research areas was to maximize worker efficiency and output to increase capital. Rather than associating products with the physical work and social relations needed to create them, products became associated with their material worth, thereby making the individuals – as well as their minds –

commodities (Marx & Engels, 1965). This was just as relevant to workers in industry, as it was to the psychologists who studied them; they were, as a collective, enslaved to the state.

In line with Marxism, Frankfurt School scholars such as Horkheimer and Adorno (1944) took these arguments further and referred to culture as a reflection of social power and a commodity, where advertising through psychological knowledge is used as its elixir – consistently defining and redefining cultural roles in order for combines, or large corporations, to maintain power and control by capitalizing on consumer‘s naiveté. In turn, workers and consumers adopt a false consciousness, or views put forth by those in power that, on the surface, may appeal to the workers‘ and consumers‘ own interests (e.g., the promise of upward mobility) but in reality, drive the interests of the very individuals who created these views. The end result is a population that largely responds passively rather than actively in their environments.

Complementing (and driving) the theory of false consciousness, Marx‘s concept of ideology refers to the ideas people use to define their existence (Marx and Engels, 1845-49; 1970).

Consciousness, to Marx, is not a precursor to an individual‘s circumstances; rather, it is the material circumstances that individuals are placed in by the dominant class that determine how they form meaning (or become conscious) in their lives. Taken together with Marx‘s notions of ideology and false consciousness, it is in the best interest of the corporation to sell – not merely the product – but the idea of what a human ought to be, making the mechanisms of ―branding‖ that much easier. It also aids in making individuals believe in the naturalness of their identity as a hybrid one, assorted from a combination of ―producer‖, ―consumer‖, and ―commodity‖, instead of a moral, agentic citizen. This becomes particularly important to consider when analyzing the bioethics of socially marketing mental disorders and psychopharmacotherapy, as seen in Chapter

III.

How Cognitivism and Humanism retained the Stimulus Response Model

Cognitivism largely asserted that the mind was completely suppressed by the behaviourist model and coalesced to start another movement in Psychology in the mid-20th century. Although Skinner and other radical behaviourists reintroduced the mind to the stimulus

–response model, cognitivists, through ―bouts of academic fisticuffs‖, put the mind on a pedestal

(Lovie, 1983, p. 301). However, even with the stimulus-mind-response model, there is limited room for intentionality and agency, as the model assumes a direct representative link between people‘s language and their cognition; additionally, the notion that individuals form ―schemas‖ suggests that people‘s perceptions are relatively static throughout their lives (R. Coughlan, personal communication, March, 2014). Again, we see that the individual‘s mind is merely passively responding to the environment, integrating sensory information within their personal schemas, and responding according to these schemas in the future. This assumption of humans as relatively static and passive responders has been discounted by discourse analysts who often find that people‘s attitudes, goals, and actions are inconsistent across situations (Potter & Edwards,

1999; Stephenson, Wolfe, Coughlan, & Koehn, 2000). Here, language is seen as a social and goal-oriented action, in which the person is an active agent of their experiences.

This representationalist assumption of cognitivism assumes a dualist position, whereby the ―stuff‖ that is representing (the mind) and the thing that is represented (external reality) are separate, but causally linked. This is merely a reiteration of Clifford‘s (1878) notion of ―mind- stuff‖; that the mind is an aggregate of physical matter capable of perceiving reality in its truest form. Additionally, it is another form of positivism; owing to the assumption of a one-to-one correspondence between mind and reality (also known as the correspondence theory of truth),

cognitivists assume that the human mind is capable of being a vessel of absolute truth (Willig,

2013). Again, we see the God‘s eye trick at play here, since it underlies many state-driven ideologies (Haraway, 1988). According to Arrigo & Fox (2009), rather than challenging the assumptions that justify violence, much of cognitive theory is used in the development of legal- system tasks dealing with counter terrorism, lie detection, and decisions on how people should be punished. Another example is cognitivism‘s strengthening of the medicalization in mental health practice – i.e., it helps reduce psychological issues to diagnostic categories that are amenable to scientific management. Finally, and most regressively, cognitivism emphasizes the adjustment of mental processes (i.e., the individual) to promote mental health, rather than the problematic issues in a given society: ―it‘s all about perspective!‖ Much of modern humanistic psychology is no better, as explained below.

A Marxist critique of Humanistic Psychology. Based on to Giustiniani‘s (1985) historical analysis of the term ―humanism‖, a critique of the humanistic school of thought is only possible when we understand how its definition has changed. For instance, Plato saw three distinct aspects of the soul (the rational, the emotional, and the appetitive), and thus acknowledged that humans can simultaneously experience intelligence, passion, and instinct.

Later, Aristotle (and even later, Cicero) noted that individuals are innately curious but will sometimes desire immediate, hedonistic pleasure over knowledge. Finally, humans can be self- sacrificing and empathic, while also being ruthless, vengeful, and violent. All these paradoxes, as

Giustiniani (1985) noted, are at the very core of humanity.

The two major shifts in humanism that are important to note here are those of the

Medieval Latin period and the humanistic movement in Psychology. Prior to the Medieval Ages, being human (or humanus) meant being both ―benevolent‖ as well as ―learned‖, however as

classic Latin became dominant around the time of the late Roman Republic, the ―learned‖ facet was dropped. Therefore, humanity became associated solely with benevolence, or having a desire for goodwill towards the community. This is still, by and large, the accepted definition of human or humanitarian today (Giustiniani, 1985). However, humanistic psychology has largely been ontologically and epistemologically distorted.

On the surface, humanistic psychology is associated with human agency and intentionality (Nord, 1977; Robbins, 2008); it is associated with the same benevolence that defines being human, as it supports hope and empowerment (which was no more than a reaction to Freud‘s pessimistic view of humanity) (Islam & Zyphur, 2001). Currently, there are two distinct branches of humanism. The biological, or Maslovian branch posits that humans are motivated by self-actualization, which can only be possible after their biological needs are met

(Maslow, 1943). Similarly, the transcendental branch suggests that humans are capable of separating themselves from their physiological, social, and environmental circumstances to move beyond (or transcend) their best possible selves, in an otherworldly, almost Godlike state

(Hartelius, Caplan, & Rardin, 2007). If we use a Marxist perspective to understand humanistic psychology, we can see that a number of sociological forces have largely been neglected by so- called ―humanists‖ whose supposed goal is to promote human agency (Nord, 1977; Robbins,

2008).

Similar to previous schools of thought, the humanist school is centered on the individual; there is no room for interdependence, which is what Marx (1906) claimed to be pivotal for the advancement (or actualization) of our species. Marx (1906) and Mead (in Mead & Mind, 1934) both postulated that only humans are capable of exercising self-conscious activity (i.e. agency and intentionality); and without it, we cannot fully experience our humanity. Although the

stimulus-response paradigm was somewhat abandoned by the humanists, aspects of dualism (i.e. current self versus self-actualized self) still exist within this school.

This is seen more clearly when we understand that humanistic psychology does not always view humans from a humanistic lens, but rather an economic one, whereby the individual needs to realize their function of personal utility in order to ―transcend‖ (or become ―self- actualized‖). Putting self-actualization within a hierarchy of needs turns self-actualization into a utility, in and of itself. As the need for human efficiency or utility became necessary to maximize capital, the hierarchy of needs was, inherently, the hierarchy of a post-war American value system (Islam & Zyphur). In short, the individual is only valued in as much as they can be a utility to the industrial complex. As we saw earlier, what is deemed useful or pragmatic is determined by those in authority, whose main focus is on individual differences (e.g., in cognitive ability, motivation, aptitude, and personality). The purpose of this is selection, recruitment, and maximum efficiency within an organizational context. Therefore, the individual is neither agentic nor intentional within this value system since self-actualization is associated with business success – which, as we saw earlier (during the discussion of false consciousness), is the success of those in power, rather than the working class as a whole.

Current School of Thought

The current dominant school of psychology is a North American behavioural-cognitivist- humanist hybrid which still vastly undermines the human potential of personal agency by side- stepping the political and cultural forces that create human suffering. For instance, cognitive and humanistic psychology are similar to the stimulus-response paradigm in that the ‗stimulus‘ is either a biological drive (i.e. physiological or environmental stimulus) or a transcendental drive

(replacing God as the stimulus) (R. Coughlan, personal communication, March, 2014).

Mainstream psychologists and their advocates have therefore, unfortunately, become the archetypes of voluntary intellectual submission (Marková, 2012). In other words, rather than viewing the hierarchical arrangements of an elite society as problematic and understanding how mental health issues are a by-product of the industrial complex that they inhabit, the current schools are collectively grounded in a methodological solipsism, and therefore put the onus of mental health and illness on the individual (Fodor, 1980; Marková, 2012).

What makes matters worse is that this system of knowledge is not only affecting communities in the Western world (e.g., by socially breeding the ―worried well‖), but it is dominating what ―mental health‖ and ―mental illness‖ can mean in other cultures. In other words, psychology is largely being used as a vehicle for global scientific colonization and has, in many ways, replaced spirituality, religion, or God, as the governing forces of society, which can do more harm than good for many non-Western communities. Some of the practices within psychoanalysis, clinical psychology and psychiatry are good examples of how psychological inquiry can be exploited to disempower individuals and societies – both in the Western and non-

Western worlds. Of particular importance is an understanding of how the International Statistical

Classification of Diseases (ICD) and the Diagnostic Statistical Manuals (DSM) have been revised over the course of several decades and spawned the global use of what some critics characterize as a ―Western‖ metacategorizational system of mental disorders (Castillo, 1997;

Marecek & Hare-Mustin, 2009). These are discussed in Chapter II.

Chapter II. Mental Healthcare and the Classification of Insanity

Modern mental health care saw its most rapid growth during the overlap between the Age of Enlightenment and the Industrial revolution. The Age of Enlightenment inspired humanitarianism and the notion that reason should be given more power than religion, while the

Industrial Revolution spurred urbanization, technological innovation, and capitalism (Danziger,

1982; Gold & Gold, 2014; Saul, 2009). The direct effect of these two revolutions can be seen in how the various modalities of psychological practice are each at odds with others and result in bouts of academic and professional conflict (Buss, 1995; Greenberg, 2013). Ultimately, mental health advocates, owing to these conflicts, have generally lost sight of the philanthropic intentions that inspired more ancient forms of mental health care. This suggests that mental health care represents two fundamental types (Greenberg, 2013). The first is innately altruistic and humanitarian; to alleviate suffering by understanding both ourselves and others. The second, more Machiavellian one, is the drive to manipulate and control the forms and outcomes of others‘ lives to our own advantage – whether it be in the form of prestige, power, or monetary gains, which often go hand in hand (de Waal, 2007; Applbaum 1998). For the Freudian reader, the former loosely represents aspects of our super ego, while the latter, aspects of our id (Freud,

1923; 1930). Ironically, the field of mental health care itself has been in a constant battle between these two poles since its inception.

The Roots of Insanity

The history of what we construe as madness began long before the mental health field was established (Shorter, 1998). Similarly, the establishment of the Diagnostic and Statistical

Manual of Mental Disorders (herein referred to as the DSM) as the sine qua non of clinical practice began centuries before its first publication (DSM-I) in 1952 (Castillo, 1997; Gold &

Gold, 2014). Psychiatry and therefore the forerunners of the DSM began taking shape between the Middle Ages when the Asylum was established and approximately 200 years ago when psychiatry was first recognized as a scientific discipline (Castillo, 1997; Gold & Gold, 2014;

Greenberg, 2013). Prior to discussing the classifications of mental disorders, it is important to understand the medieval concepts of madness, as well as how and where ancient mental healthcare developed. After all, humans ―probably wondered about madness ever since they could wonder about anything‖ (Gold & Gold, 2014, p. 21).

An ancient portrait of humanity and medieval concepts of madness. If we examine the nexus of evolutionary psychology (e.g., Buss, 1995; 2005; Gould, 1991), anthropology (e.g., de Waal, 2006; 2007; 2009), neuroscience (e.g., Sapolsky, 2005), and sociology (Mead, 1925), we can see that living in a collectivist society and working together was extremely adaptive. The concept of social cohesion – or loyalty to one‘s group or tribe, as seen in our closest primate relatives – existed before the idea of spirituality and religion were even formulated (de Waal,

2006). Additionally, evidence of ritualistic burials that were seen during the Paleolithic era approximately five hundred thousand years ago from modern day Mediterranean, Middle East and North Africa regions (e.g., Pettitt, 2002; Solecki, 1975) suggest that the idea of collective, symbolic interactions (i.e., culture) between people were crucial in building empathy and bringing us together, thus predisposing our brains to develop structures that make complex language possible (Dunbar, 2003). In short, collective culture followed by language became essential for our survival, however, it also meant that we could construct more abstract explanations about ourselves, our environments and the people around us.

Madness or insanity – primarily discussed today in terms of delusions, paranoia or psychoticism – were experienced as early as the onset of human civilization, and were seen in light of an individual‘s natural surroundings (Gold & Gold, 2014; Greenberg, 2013; Stein, 2000).

However, when exactly humans began replacing their connection to nature (i.e., spirituality) with their connection to God (i.e., religion) is historically fuzzy. Although Hinduism dates back to approximately 4,000 years ago and is considered to be the world‘s oldest religion, Gold and Gold

(2014) suggest that it wasn‘t until 3,500 years ago (approximately 1550 BC) in Egypt, and 500 years later in India, that demonic possession was thought to be the source of abnormal behaviour.

As an example of how abnormal behaviour was construed prior to the introduction of religion we can examine how societies in the Middle East and Ancient Greece viewed mental illness before and after Abrahamic religions – such as Christianity, Judaism, and Islam – were introduced about 1,500 ago (see Stein, 2000). During the first millennium BC (2,000 – 3,000 years ago), ancient Berbers of North Africa colonized the mountains and deserts of what is modern day Morocco and were very in-tune with nature (Stein, 2000). Traditionally, the Berbers were animists in that they believed that their natural environments had mystical significance and that they were spiritually and physically connected to it. In other words, there was very little distinction between self and nature, and no distinction between the ‗bodily self‘ and the ‗mind self‘. Abnormal behaviour was instead associated with evil contained in natural objects of the environment ―in a form that [they could] touch, taste and feel‖ (Stein, 2000, p. 1,468).

Around the same time in ancient Greece, insanity was viewed as a gift of divine origin, as seen in Homer‘s Odyssey: ―the gods are putting lunacy into the clearest heads around‖ (in Gold

& Gold, 2014, pp. 18-19). This was largely until Hippocrates, who is considered to be the father of modern medicine and medical ethics, conceptualized madness as a disease of the brain –

approximately 500 years before Christianity was introduced to Europe (Kleisiaris, Sfakianakis,

& Papathanasiou, 2014; Rives, 2006). However, he also argued for a more holistic approach to medicine (unlike the Knidos physicians who were more disease-centered) since he followed

Asclepius and the Methodists (medical thinking) and instructed physicians to conduct thorough medical histories and physical examinations of his patients – leading to the formation of modern

‗evidence based medicine‘ (Kleisiaris et al., 2014). He also (supposedly) argued that it is more important to know the patient who has a disease (including full details of the environment that they inhabit) than it is to know the disease itself. Additionally, he felt that a physician‘s goal is to help their patients harmonize with their social and natural environments (Kleisiaris et al., 2014;

Gold & Gold, 2014, p. 155). Despite this holistic approach, however, Hippocrates paved the way for his disciples and future physicians to view madness as something that originated from an individual‘s brain and the body, rather than their natural environment (Gold & Gold, 2014).

Later, even Plato wrote about the four faces of madness: the prophet, the poet, the mystic, and lover, which echoed Homer‘s perception of madness as divinity. However, this perception was also soon abandoned since ―Hippocratic‖ medicine had already gained rapid momentum (Gold &

Gold, 2014; Hackforth, 1952).

The concepts of God and the Devil did not exist in Ancient Greece until Christianity and

Islam were developed (Gold & Gold, 2014; Rives, 2006; Saliba, 1995; Sedlaceck, 2011). To the

Israelites, Babylonians and Mesopotamians (who occupied what is now modern day Israel, Iraq,

Kuwait, and Syria), erratic behaviour was seen as a curse or punishment to those who disobeyed

God. As Christianity and Islam spread to North Africa approximately 1,500 years ago, the

Berbers also began associating abnormal behaviour with demonic manipulation (Stein, 2000).

While both Islam and Christianity took over Middle Eastern, North African (and eventually

North Indian) regions, Christianity also branched out to Europe and became conflated with

Hippocrates‘ view of madness as a brain disease. This became a defining moment of Western mental healthcare as we know it today.

The Origins of Mental Health Care

We first started seeing the mentally ill lose their rights such as those linked to marriage and procreation under medieval religious rulership (Gold & Gold, 2014). This rulership, however, also encouraged the establishment of charitable hospices. The first examples of these well-intentioned hospices originated in the Jewish and Arab world between the 12th and 14th centuries (Horden, 2005; Gold & Gold, 2014; Riva & Cesana, 2013; Scull, 1981). For example,

Jerusalem established a ward for those who were thought to have a mental illness, and Sultan

Bajazet II of the Ottoman Empire ordered that the mentally ill be treated with respect, housed in humane environments in more natural surroundings, and encouraged to have healthier diets and engage in more creative activities (e.g., music). In fact, even in modern cultures, the importance of being ―in nature‖ after having a ―shamanic experience‖, or what some may characterize as a

―psychotic‖ episode can be important for communities (e.g., such as those in North Africa) in which healing is more probable when an illness is viewed in light of external explanations, rather than internal states (McGrudder, 2002; 2004). This is largely owing to the fact that individuals who have these experiences have a place in society rather than being fragmented from it.

One of the first hospices that attended to an individual‘s emotional and spiritual needs during times of suffering was called Jundi-Shapur (meaning Beautiful Garden) in Persia (ancient southwest Iran). It was originally established to house Greek prisoners, but quickly became a hospice for Greek refugees after the Byzantines (Eastern Romans) destroyed the Athenian school

(Miller, 2006). It was here that the Greek, Persian, Zoroastrian, Indian, Jewish and Nestorian

philosophers, philanthropists and physicians came together and established a tolerant, peaceful and communitarian hospice for anyone who experienced any form of physical or emotional suffering, regardless of creed or wealth (Miller, 2006). It was essentially a more integrated and holistic form of community care.

Meanwhile in 13th century Europe, the number of insane asylums were beginning to multiply. The most famous one was the Bethlem Royal Hospital in London (later, notoriously known as ―Bedlam‖), founded in 1247 and established as Europe‘s first psychiatric hospital in

1330 (Gold & Gold, 2014). By the late 1300s, Bethlam became a melting pot for the mentally ill and like many smaller asylums in Europe, relied on funding from the upper class to keep them running. After the Mongolian destruction of ancient Syria, Iran, and Iraq in the 1200s as well as the Spanish conquest at the turn of the 1500s, the holistic and philanthropic traditions of what we now call ―indigenous cultures‖ were lost to the Western world (Miller, 2006). This included the annihilation of naturalistic and super-naturalistic Aztec medicinal practices when the West invaded South America (Singer & Baer, 2011). The Aztecs, who were the indigenous population in modern-day northern Mexico, constructed healing practices that were grounded in the belief that disequilibrium in the universe caused disequilibrium in the human mind and body. Both male and female physicians and shamans worked together to communicate with deities, and used medicinal and hallucinogenic plants and to treat patients. The Aztecs even had trained surgeons to perform operations on those who fought in the Aztec battles as they raised their empire – which came to an end as the Spanish colonized Central America (Singer & Baer, 2011).

The Western destruction of holistic and charitable practices on an almost global scale marked a crucial turning point in the Western mental health care system because asylums started to become businesses (Gold & Gold, 2014). For example, since taxes and wealthy landowners

ran Bethlam, the church slowly lost its control over the hospital resulting in its gradual secularization; this is when we began seeing their conditions, treatment of their inhabitants, as well as the attitudes towards ―mentally disturbed persons‖ deteriorate even further (Dain, 1989, p. 3; Gold & Gold, 2014). We can see insanity being reified as a brain disorder through books and articles devoted to mental illnesses and their treatment around the turn of the Enlightenment period in Europe (Gold & Gold, 2014). The first of these, The Diseases which Deprive Man of his Reason by Paracelsus (1567), propagated the notion that nature, rather than demonic or divine manipulation, is the sole origin of brain diseases. About five decades later, Button published Anatomy of Melancholia, which recommended treatments such as diet, exercise, music, marriage, and herbal remedies in the event that more medieval practices such as bloodletting, purgatives, and laxatives failed (Button, 1621, as cited in Gold & Gold, 2014; Dain,

1989). A century later, the idea that the brain (and later the mind) was responsible for mental disorders became more concrete through written texts such as A New System of Spleen, Vapours, and Hypochondriak Melancholy (Robinson, 1729) and Observations on Maniacal Disorders

(1792) – which all acted to perpetuate the inhumane treatment of the ―poor Lunatiques‖

(Hogarth, 1735, as cited in Gold & Gold, 2014, p. 23). It wasn‘t until the end of the

Enlightenment period in Europe that the poor treatment of inmates temporarily subsided to be replaced by the more humanitarian aspirations of Psychiatry (Tuke, 1813).

The birth of Psychiatry. The Age of Enlightenment (1650s to 1780s) and the Industrial

Revolution (1760s to 1840s) in Europe were important eras for mental health care since it was during this time that we began seeing humanitarianism as well as individualism (i.e., which was highly connected with the ideas of the Cartesian Mind, discussed later in the chapter) run parallel to each other. Many of the movements in modern mental health care began taking shape towards

the end of the Enlightenment period and into the Industrial Revolution when humanitarians, including physicians, began protesting against the horrific conditions of the asylums. Some of earliest detailed accounts of the inhumane treatment of the mentally ill were from wealthy landowners and physicians in the 1700s and 1800s (Shorter, 1997, as cited Gold & Gold, 2014;

Marneros, 2008; Shorter, 1998). For example, the treatment of the mentally ill in the 1800s – generally denoted as ―village idiots‖ – was illustrated in an account of a member of an Irish

House of Commons:

There is nothing so shocking as madness in the cabin of the Irish peasant… When a

strong man or woman gets the complaint, the only way they have to manage is by

making a hole in the floor of the cabin, not high enough for the person to stand up

in, with a crib over it to prevent his getting up. This hole is about five feet deep, and

they give this wretched being his food there, and there he generally dies (Sessional

Papers by The House of Lords, Ireland, as cited in Shorter, 1998, p. 1-2)

Similarly in Normandy, the 1785 demolition report (see Gold & Gold, 2014) of

Chantimoine Tower that housed the criminally insane described a man named Jean Heude

(―Bane‖), who, owing to his violence, was locked away without release for so long that ―the lock had to be knocked off with an iron bar‖ (p. 22). About two decades later in Bethlem, a US marine named William Norris became more violent than other inmates and was locked away for ten years with ―a chain around his neck that could be tightened from an adjacent room‖ (Gold &

Gold, 2014, p. 22). It is difficult to know whether Norris was in fact too dangerous to be treated like other inmates or if his violence was a natural and reasonable reaction to the inhumane conditions of the asylum.

It was the general atmosphere of growing outrage towards these conditions through which

Psychiatry was born. The two physicians who established the discipline were Philippe Pinel and

Johann Riel (Gold & Gold, 2014). Pinel, an asylum doctor at the Salpêtrière Hospital in France, was heavily influenced by the revolutionary aspirations of his generation, and decided to unchain its inmates in 1793. A decade and a half later, Reil, who described German asylums as

―antiquated prisons‖ where the mad were ―gripped by chains, corrupting in their own filth‖, coined the term Psychiatry (Gold & Gold, 2014, p. 22).

As we can see, history has a way of repeating itself; the humanitarian concerns of psychiatrists in the 18th and 19th century in Europe were beginning to resemble those of the philanthropists, medical doctors, and intellectuals of 13th and 14th centuries. Unfortunately,

Psychiatry was born in an industrial era that was beginning to dictate how healthcare would be run. In other words, psychiatrists needed to establish themselves as a discipline worthy of respect in the age of science and harmonize with a capitalist environment (Danzinger, 1994; Greenberg,

2013). They did this by demonstrating that the mentally ill could be ―treated‖ rather than merely

―confined‖ (Gold & Gold, 2014). This was when science began to replace religion as the epistemological system utilized in understanding the reason for insanity and the onus of mental illness (as well as mental acuity and giftedness) fell on the individual rather than limited to external concepts (nature), or higher transcendental (religious) sources. Those who could demonstrate that an individual was inferior both in the name of God and science was in an even higher position of power to rule concerning matters of insanity. After all, ―the power to give names to our pain is a mighty thing and easy to abuse‖ (Greenberg, 2013, p. 7).

Early classification systems. During the Industrial Revolution, the need for maximum efficiency in the workforce (sometimes called the ―Victorian cult of improvement‖) could not

have been met without civilizing the ‗savage‘ in the name of morality – and it was ultimately up to the state to dissect humanity using ‗science‘ (Davis, 2009, p. 11). ―We happen to be the best people in the world with the highest ideals of decency and justice‖ said Englishman Cecil

Rhodes during India‘s occupation in the late 1800s, ―[as well as] liberty and peace, and the more of the world we inhabit, the better it is for humanity‖ (in Porter, 2014, p. 35). Similarly, when

George Nathaniel Curzon, representative and viceroy of India was asked why Indians were not employed in their own government, he argued that ―among all 300 million people of the subcontinent, there was not a single man capable of the job‖ (in Davis, 2009, p. 12). By this time, as Davis (2009) recounted, the industrial revolution was in full force and biologists, psychologists and even anthropologists pawned themselves to the pseudoscientific enterprise.

Their methods included phrenology and measures of hip size, hair texture and skin colour to support their bizarre notion that the upper class White males were superior according to

Linnaeus‘ sub-species of Homo sapiens: afer (African), americanus (Native Americans),

Asiaticus (Asian), Europaeus (European) and finally, the real kicker, monstrous, which included everyone who appeared far too absurd to be worthy of classification (p. 12).

The classification system of mental disorders began with a man who went by the name of

Samuel Cartwright (Greenberg, 2013). Cartwright was a physician in New Orleans who had also studied Greek nomenclature. In 1850, in the spirit of assigning names to medical disorders, combined with the need to rationalize slavery, Cartwright constructed ―drapetomania‖ from drapetes (―runaway slave‖) and mania. The literal translation for drapetomania was ―the disease causing Negroes to run away‖ (p. 1). The primary symptom (in addition to being a Negro) was

―absconding from service‖. Of course, there was a milder form of the disease, which he called dyaesthesia aethiopica, which affected the mind and body and caused slaves to ―slight their

work‖ (p. 3). But like all diseases, drapetomania needed a cure and the one that he felt had the highest success rate was ―whipping the devil out of them‖ (p. 2). Some physicians obviously doubted Cartwright‘s theory, therefore he ventured to demonstrate its validity by arguing that the

Canaan people – Canaan meaning ―submissive knee bender‖ – were the ancestors of Negroes, therefore they were brought on earth, by God, to serve upper class men of Euro-American origin

(p. 2). His ‗scientific‘ proof for this was the Linnaean taxonomic system that suggested Negros were a different subspecies of humans. A second line of proof came from European physicians who demonstrated that Negro blood and musculoskeletal systems were ‗darker‘ and ‗weaker‘ than European blood. Therefore, despite some skepticism from physicians working in the northern states, Cartwright defended his theory in the name of both God and science: it wasn‘t the Negro‘s fault for wanting to flee. He was merely genetically and therefore morally inferior and ill (Greenberg, 2013).

Ultimately, if you were black or ‗coloured‘, a woman, or gay, you were viewed as ‗lower class‘, which meant that physicians could cure you. However these early classification systems were clearly not designed to alleviate suffering; they were merely an expression of intolerance towards anyone deemed to be a second-class citizen. The enthusiasm with which Emil

Kraepelin‘s classified subjective, internal ‗traits‘ echoed that of biologists and phylogeneticists who were tracing the evolutionary history of plants and mostly non-human mammals based on their actual physical traits and tangible, microscopic evidence (Greenberg, 2013, p. 5).

Distinguishing between different types of madness. Regardless of how much mental health practice has been attributed to Freud, Emil Kraepelin – who happened to be born in 1856, the same year as Freud – laid the foundation upon which the modern classification system was

built (Gold & Gold, 2014; Greenberg, 2013; Morris, 2015). In fact, Freud was highly against the classification system and had enough academic and professional progenies who began separating into their own school (this is when we began seeing psychiatry and psychoanalysis diverge).

Likewise, Kraepelin felt that the unconscious could not be observed and quantified, therefore he ventured to develop his classification system by using the methods of surveillance in a controlled laboratory setting and keeping very detailed records of his patients (Decker, 2007; Gold & Gold,

2014). Kraepelin was the first to argue that there was not one madness, but several different types of madness. He noticed that many of his patients‘ emotions were fleeting from a spectrum of euphoria to melancholy. He decided to call this manic-depressive psychosis (Kraepelin, 1902, as cited in Gold & Gold, 2014).

The other type of illness he noticed was severe cognitive impairment, which he called dementia praecox; as the story goes, Eugene Bleuler later renamed it schizophrenia, owing to his

‗observation‘ that the phren (Greek for ―mind‖) was capable of experiencing skhizein (Greek for

―spliting‖). Therefore – not unlike Cartwright‘s construction of drapetomania – by combining skhizein-phren (which almost sounds like something Hitler would scream while commanding his troops), he was able to fashion ―schizophrenia‖ which literally translates to ―split mind‖ – a perception that still persists today (Castillo, 1997, p. 246; Gold & Gold, 2014). Kraepelin also introduced psychiatry to ―paranoia‖ (which was later renamed to delusional disorder) because he noticed that some of his patients had poor judgement in that they were beginning to worry about how external, authoritative forces of power wanted to watch or control them (Decker, 2007; Gold

& Gold, 2014; Kendler, 1988; Munro, 1999). Finally, through successive revisions of his textbook, Psychiatrie. Ein Lehrbuch für Studirende und Aerzte (German for Psychiatry. A

Textbook for Students and Doctors), he introduced his classification system to international

scholars and word (literally) spread to the United States (Kraepelin & Diefendorf, 1915; Gold &

Gold, 2014). Eventually, the taxonomy of mental diseases began proliferating exponentially and provided the model for contemporary psychiatric diagnoses (Danziger, 1997; Decker, 2007;

Greenberg, 2013).

Kraepelin was considered to be a pioneer because he focussed on the prognosis of what he thought were different disorders within laboratory and clinical settings – first in Germany, and then in an Estonian asylum – with the hopes of being able to predict the outcome of a disease based on preliminary symptoms (Gold & Gold, 2014; Morris, 2015). Kraepelin felt that his inability to speak Estonian was to his advantage, because it meant that he wouldn‘t be distracted by empathy and could remain more ―objective‖. ―Trying to understand another human being‘s emotional life is fraught with potential error‖ said Kraepelin, ―it can lead to gross self-deception in research‖ (Morris, 2015; p. 154). Therefore Kraepelin, along with some of his most influential followers such as Robert Spitzer (who we‘ll see was a key figure in the DSM Task Force, which he now regrets) became, at the very core of their intellectual and moral identities, ―true empiricists‖ (Greenberg, 2013; Grob, 1991, Spitzer, 2012). Kraepelin even sought an apprenticeship under Wundt after he opened his laboratory in Leipzig in 1879 in an attempt to use experimental psychology to support his classification system, and, in 1917, founded the

German Institute for Psychiatric Research (Decker, 2007). This served as a model for American researchers who changed The American Medico-Psychological Association (formerly known as

The Association of Medical Superintendents of American Institutions for the Insane) to the

American Psychiatric Association in 1921 (Decker, 2007; Greenberg, 2013; National Institutes for Health, 2014).

In short, the foundation of the American Psychiatric Association is built on two rather shaky pillars: the first is a Linnaean (biological) taxonomy adopted by Southern U.S. slave owners to justify slavery, and the second is a Kraeplenian set of diagnoses that were constructed using German and Estonian patients of an ―empiricist‖ who couldn‘t even speak the native language of many of his patients. The original pillar of psychiatry – that of humanitarianism – was so severely fragmented by the time the U.S. Census Bureau dug their claws into Psychiatry that it became a distant childhood memory in what was now emerging to be what critics describe as a warrior discipline that would begin to dominate the world view of mental health and illness

(e.g., Applbaum, 2006; Watters, 2010). To demonstrate that I am not, in Greenberg‘s (2014) words, ―taking a cheap shot‖ (p. 4), or in Reicher‘s (1996) words, being ―melodramatic‖ (p.

231), let‘s continue to look at how the Kraeplenian model progressed from US Census Bureau reports on incarcerated immigrants to The Statistical Manual for the Use of Institutions for the

Insane, and finally to the DSM-I to DSM-5 while still retaining its original purpose to predict and control not only the U.S. population but also the global mind-set regarding appropriate mental hygiene and appropriate behaviours.

Wundt‘s and Münsterberg‘s (initial) warnings against the attempts of using natural science to understand consciousness (Vygotsky, 1980; Münsterberg, 1898a), as we saw in

Chapter I, were obviously ignored by neo-Kraepelinian psychiatrists. Unfortunately for

Kraepelin, there were far too many gaps in his theories pertaining to localization, histology and genetics for him to compete with the biological sciences. Combined with a lack of statistical information – which was crucial to the U.S Census Bureau during World War I – psychiatrists could not see their work move forward, let alone receive funding from the U.S. government

(Danziger, 1994; 1990; Greenberg, 2013). Therefore Kraepelin, prior to his death, never saw the

fruition of his foundations and his journal Psychologische Arbeiten (Psychological Works) ceased publication after nine volumes (Danziger, 1997).

Kraepelin needed to compete with Freud‘s theories as well as medical advances being made during World War I. In other words, in order to receive funding, he needed to give the state something that was useful to them. Kraepelin‘s rationale for not being able to provide hard evidence was that technology wasn‘t advanced enough therefore he urged psychiatrists to thoroughly document their observations of their patients until they became predictable. He also promised that his theories would be supported by psychiatrists in the future (and he was right, or so it seemed), who would localize insanity anatomically to be able to better cure it. This, however, required full approval from the U.S. Census Bureau as well as the formal acceptance of physicians who were practicing non-psychiatric medicine.

Psychoticism:qu'est-ce que c'est? In the spirit of word-play, Kraeplin constructed several dubious categories of illness, including masturbatory insanity and wedding night psychosis, but he couldn‘t exactly say where one ended, the next one began, or whether or not they even existed (Greenberg, 2013; Grob, 1991). Medical critics such as Steward Paton argued that these diagnoses did not deal with ―definite disease entities, such as typhoid fever or pneumonia‖ and suggested that psychiatrists instead categorize mental diseases into ―defect psychoses – idiocy, imbecility, and other degrees of mental debility‖ along with manic- depressive insanity and dementia praecox (pp. 423- 424). Therefore, in 1907, Charles Hill

(president of The American Medico-Psychological Association) suggested that psychiatrists follow the medical experts‘ advice because without adding ―the classifying mania of medical

authors‖ psychiatrists had no hope to gain any prestige or respect within the medical community

(Grob, 1991, p. 424).

Devising a classification system was more beneficial to the American elite (of Northern and Western European descent) whose ―race‖ was, at the time, viewed as being under threat because of the large numbers of immigrants (including Eastern and Southern Europeans) who were landing in the United States (Grob, 1991; Greenberg, 2013). By this time Adolph Quetelet had already introduced statistics to other social sciences such as psychology and sociology

(Beirne, 1987). Therefore, while experimental psychologists such as Cattell were measuring individual differences to support the eugenics movement in the United States (which occurred before – and even inspired – the eugenics movement of Nazi Germany in 1933), the U.S. Census

Bureau developed several reports that assumed the relative inferiority of immigrants (Grob,

1991). For example, the 1904 census, which was based on the American Public Health

Association‘s president‘s Report on the insane, feeble-minded, deaf and dumb, and blind in the

United States (Billings, 1895), described the ethnic and racial characteristics of incarcerated immigrants who the association deemed to be mentally ill. This report was based on seven forms of insanity including acute and chronic mania and melancholia (among others such as epilepsy and general paralysis), and was used as proof that the mentally ill be involuntarily sterilized – which they inevitably were (Haller, 1963 as cited in Grob, 1991).

Despite criticisms from political theorists such as Hill – who demonstrated the methodological and statistical errors in the report – the U.S. Census Bureau turned to the

Medico-Psychological Association in 1908 to appoint a committee of psychiatrists to collect data on mental diseases. The psychiatric committee, initially refusing to collect data owing to the fact that ―the classification of mental diseases is chaotic‖ and would therefore ―reflect unfavorably‖

on psychiatrists (Grob, 1991, p. 425), had no choice but to develop a nomenclature lest the

Census Bureau cut their funding. Therefore, psychiatrists began resurrecting Kraepelin‘s disease categories and, for good measure, even incorporated neuroses and reactions and other Freudian jargon to construct twenty two individual psychoses which were listed under the Statistical

Manual for the Use of Institutions for the Insane which the census bureau was able to use as an excuse to ban or incarcerate newly landed immigrants from entering the United States (Gold &

Gold, 2014; Greenberg, 2013).

After World War II, however, the Statistical Manual, which was designed for immigrants and emphasized the concrete rather than transient nature of mental illnesses, could not explain why American soldiers felt traumatized after the war. Psychoanalysis had the same issue. It emphasised early childhood experiences as the source of distress therefore it couldn‘t explain why seemingly healthy adults with happy childhoods were showing ―neuroses‖ after coming back from experiencing the traumatic events of industrial scale warfare (Greenberg, 2013, p. 31).

Therefore, the Veterans Administration took the opportunity to compete for their own categories to be published within successive revisions of the manual (Greenberg, 2013). Consequently psychiatry, once again, experienced an identity crisis. On the other hand, adherents of psychoanalysis (which had already gained a substantial foothold in the United States when Freud landed there in 1909), had less trouble making therapists adapt to these new symptoms (Gold &

Gold, 2014). It‘s not as if Freud could complain as he died just as the second world war began, so the term psychoneurotic reaction was adopted (Greenberg, 2013) and was met with the same

Jamesian (i.e., functionalist) and Watsonian (i.e., behaviorist) view of humanity that dominated

American industrial society: that our purpose is to consistently adapt (or respond to) changing

(often manipulated) environmental circumstances (stimuli) (James, 1890; Orange, 2001; Watson,

1919). The object of this exercise was to collect data by way of surveillance and to manipulate living conditions of large urban populations so that they were amenable to behaving predictably, and if not, to use the concepts of psychiatry to control them.

Constructing the DSM

The DSM-I: psychiatrists mark their territory. In 1948 (post World War II), the American

Psychiatric Association chair, George Raines, ordered the association‘s followers to give The

Statistical Manual a complete makeover (Greenberg, 2013). Psychiatrists naturally obliged and began combining disorders from various sources. The first was the World Health Organization‘s

(WHO) 6th edition of the International Classification of Diseases (ICD-6), which was heavily influenced by the Veteran Administration‘s and psychoanalytic school‘s ideas and concepts including psychoses and psychoneuroses observed among soldiers (American Psychiatric

Association, 2015; Greenberg, 2013). Further input was sought from various psychiatrists across universities and hospitals in the United States, the most notable one being Adolph Meyer who proposed the adoption of a biopsychosocial model of mental disorders (Castillo, 1997).

Additional recommendations came from association members, including those who were influenced by psychoanalytic theory, therefore the language in the revised manual became more etiological than descriptive (Castillo, 1997; Gold & Gold, 2014; Greenberg, 2013).

Since the National Institute for Mental Health (NIMH) was established, the collection of census data was taken over by government officials, allowing psychiatrists to focus more on the causality of mental disorders and formulate labels such as anxiety reactions or depressive reactions (Castillo, 1997; Greenberg, 2013). This new manual, containing 106 different disorders in 145 pages, was submitted to the association in 1950 and finally published under the name of

The Diagnostic and Statistical Manual: Mental Disorders (DSM-I) in 1952 (American

Psychiatric Association, 2015; Castillo, 1997; Greenberg, 2013; Gold & Gold, 2014).

The DSM-II: replacing the straightjacket with pharmacology. The DSM-II was emblematic of the shift from incarceration to pharmacology that occurred in mental healthcare, which was, interestingly, driven in large part by the textile industry in Europe. This shift was summarized by Gold and Gold (2014, p. 43-49). During the mid-1800s, the high demand for synthetically-dyed fabrics resulted in advances in chemistry. In 1854, German chemist Heinrich

Caro discovered synthetic blue dye which he called methylene blue. Methylene blue caught the interest of a medical student named Paul Ehrlich who was far too mesmerized by the bright colouring of fabrics to pass his medical examinations. To everyone‘s surprise, however, Ehrlich, was driven by his hypothesis that synthetic dye should chemically and selectively bind to pathogens in affected cells if they can selectively bind to fabric, therefore he ventured to put chemical dyes to medical use. His major discovery was that methylene blue attached selectively to the malaria parasite. This marked the introduction of industrial chemistry to medicine (i.e., chemotherapy). Over the next few decades, as chemists in Europe began experimenting with various dyes, one of them, named Paul Charpentier, stumbled upon a substance in 1937 that had modern antihistamine properties. He called it Phenothiazine. Navy surgeons began using it to treat battlefield injuries since it not only reduced post-operative shock in soldiers, but also reduced pain and led to a ―euphoric quietude‖ (Swazey, 1974, as cited in Gold & Gold, 2014, p.

45).

By 1950, clinical trials of Phenothiazine were carried out on animals by the Rhône-

Poulenc pharmaceutical company in France. One of the new compounds they discovered was chlorpromazine, which brought ―psychic disorientation‖ an animals (p. 44). By the 1950s and

well into the 1960s and 1970s clinical trials were carried out on human subjects and these demonstrated remarkable success with psychiatric patients whose hallucinations and paranoia subsided with these medications (keep in mind we‘re talking about a generation of psychoactive drug experimenting patient subjects). What was more astonishing was that some patients actually became responsive and exhibited normal behaviour. These discoveries resulted in a chlorpromazine (not to mention the lithium and Prozac) explosion in the pharmaceutical industry, and the French psychiatrists Jean Delay and Pierre Deniker called the drug a neuroleptic, which literally translates to ―nerve-seizing‖ (Healy, 1997; Greenberg, 2013; Gold &

Gold, 2014, p. 46). Eventually, the breaking news was brought to the United States via Canada by a French psychiatrist named Heinz Lehmann, and chlorpromazine was marketed under the proprietary name Thorazine and distributed throughout America by the Smith Kline and French pharmaceutical company (Gold & Gold, 2014).

Despite the series of coincidental events that led to the distribution of Thorazine, nobody could explain how it worked until researchers in the United States and Canada demonstrated that neuroleptics bound to dopamine receptors, leading to the ―dopamine hypothesis‖ which posited that schizophrenia was caused by dopamine hyperactivity (Howes & Kapur, 2009; Kendler &

Shaffner, 2011). A second line of evidence for the biological model was Kety‘s adoption studies which demonstrated that schizophrenia was more prevalent among children whose biological rather than adoptive parents were diagnosed with the disorder (Gold & Gold, 2014; Rosenthal &

Kety, 1968, as cited in Kety et al., 1994). This was considered to be enough evidence to demonstrate that symptoms of schizophrenia (i.e., delusions, hallucinations and paranoia) had a purely biological foundation.

Admittedly, given these two lines of evidence, the biological model is almost infallible.

By the late 1960s, the American Psychiatric Association claimed to have enough evidence – in the form of biological data, newly constructed disorders and diagnoses made by psychiatrists

(most of whom were in private practice and could claim insurance payments) – that they decided to publish a new and improved DSM-II which ran at 134 pages and had 180 disorders (Castillo,

1997; Gold & Gold, 2014; Greenberg, 2013). The number of disorders increased by approximately 30%.

A critical reflection of anti-psychiatry movements. The most pivotal anti-psychiatry movement began in the 1960s and continued well into the 1970s as freedom of speech overruled the earlier sedition acts (see Espionage Act of 1914, Chapter I), and made room for social activism (Richards, 1974; Dain, 1989; Grob, 2011). This movement began as a protest to inhumane treatments such as electroconvulsive therapy (ECT), involuntary hospitalization, and forced psychopharmacotherapy – particularly among minority groups (Castillo, 1997; Grob,

2011; Staub, 2011; Whitley, 2012). At this point, Psychiatry became ―the most criticized profession in the United States‖ (Dain, 1989, p. 3) throughout the Western world as feminists

(e.g., Walker, 1987; Widiger & Spitzer, 1991), critical social theorists (e.g., Foucault, 1965;

Goffman, 1968; Tolman, 1994), repentant psychiatrists (e.g., Laing, 1967; Szasz, 1960; 1961;

1974), public protesters, and patients‘ rights activists (see Dain, 1989) united in a way that

Psychiatry wasn‘t just criticized. It was almost annihilated.

Regardless of these protests, psychiatrists still commanded respect – and we can‘t blame them. Spending eight to ten years at university, followed by residencies, fellowships, multiple board examinations, and tens if not hundreds of thousands of dollars in debt (Ebert, & Ginzberg,

1988; Ross, Cleland, & Macleod, 2006) in addition to the medical degree that gives them a license to (and the major responsibility of) treating the body as well as the mind, we need to appreciate the fact that their desire for respect is amplified. We also need to appreciate that some psychiatrists, such as Allen Frances – who is considered to be ―one of the most powerful psychiatrists in America‖ and chair of the DSM-IV task force (Greenberg, 2013, p. 144) – may feel helpless loyalty, which is sometimes followed by contempt, towards their profession:

I would prefer to be portrayed accurately as the lowly brute I am than to be ennobled

into some version of David and Goliath... I‘m not battling the DSM-5 leadership in

some romantic crusade... There was no one else in a position to take on DSM-5 so I

was stuck... By an unavoidable duty. I started trying to warn them and now I am

trying to shame them. (Frances, n.d., in Greenberg, 2013, p. 144).

Critics in the 1960s and 1970s (e.g., Szasz, 1960; 1974), and today (e.g., Watters, 2010), have demonized psychiatry by suggesting it is a ―pseudoscientific agent of social control‖

(Whitley, 2012, p. 1039). However, according to historical analyses of the discipline, the retraction of problematic diagnoses from the DSM were largely owing to empirical studies that suggested certain behaviours were not, in fact, indicative of a psychopathology (for a historical account, see Harris, 2009). The most notable example is that of homosexuality in the DSMs I and II (under ―sexual deviations‖) which was retracted in 1973 and not mentioned as a disorder in the subsequent edition which was published in 1980. Robert Spitzer, who was chairman of the

DSM task force at the time, decided to retract it after several psychologists, gay rights activists and supportive psychiatrists collaborated in a collective effort to challenge the American

Psychiatric Association. This was only possible after demonstrating, through empirical evidence,

that well-adjusted homosexuals and non-homosexuals did not differ in their rates of psychopathology (Harris, 2009).

Unfortunately, critics (such as Thomas Szasz) often downplay the role of empirical research in changing how homosexuality was understood (Kitzinger, 1997; Harris, 2008). This results in many scholars running, in Frances‘ words, a ‗romantic crusade‘ against the whole scientific enterprise. Harris (2009), for example, admitted to being highly influenced by Szasz in thinking that ―mental illness [is] a myth created and perpetuated by a profession of moralists disguised as scientists‖ (p. 32). He further argued that history often overestimates the simple

(often inaccurate) explanation for change – that DSM executives crumbled under the humiliation caused by social activists – while underestimating the complex (often accurate) explanation – that ―political commitment and social conscience‖ executed by a whole team of researchers and gay rights supporters, including psychiatrists, had the most social impact. One of these psychiatrists was Judd Marmor, who had studied Marxism and psychoanalysis, and was a key player in having homosexuality removed from the DSM (Harris, 2009).

DSM-III: the tautology of disease-centered Psychiatry. Greenberg (2013), however, argued that removing homosexuality from the DSM was merely a petty compromise since the

DSM task force called for a new disorder, ego-dystonic-homosexuality, to account for the

―negative social attitudes [that] were internalized‖ by homosexuals. This way, the DSM task force (at least temporarily) satisfied some of their opponents while still getting insurance money for treating their gay patients (Greenberg, 2013). By 1980 the American Psychiatric Association published the DSM-III which almost doubled in size (at 500 pages) and added an additional 85 disorders for a total of 265 disorders (Gold & Gold, 2014). The primary purpose of the DSM-III

was to unite psychiatry with the WHO (the main authority of global medicine) by bridging the gap between their International Statistical Classification of Diseases and Related Health

Problems (ICD) and the DSM. This was initially a slap in the face to anyone who criticized psychiatry (Greenberg, 2013). It was a temporary but global badge of honour, and it showed, especially, when it became an international bestseller, because ―[when] you open it up, it looks like they must know something‖ (Greenberg, 2013, p. 41).

The DSM-III Task Force, led by Robert Spitzer, helped psychiatrists make ―systematic‖ and ―reliable‖ diagnoses without having to rely on the immeasurable and ambiguous psychoanalytic concept of the unconscious (Castillo, 1997; Greenberg, 2013). In fact, statistical reliability became such an important aspect of its development that the DSM completely disregarded the importance of its validity: ―increasing reliability was on… the APA‘s mind. But validity? No, no‖, he said, ―not at all‘‖ (quoted in Greenberg, 2013, p. 41). The main evidence that psychiatry had to support the medical model was from research on neuroleptics and adopted children (as discussed earlier). What was more precarious was that there was no evidence that all the listed disorders were brain diseases (Castillo, 1997). In other words, the DSM-III (in fact, the entire classification system) – which was merely a resurrection of Kraepelin‘s textbook with added statistical allure – came before any research that could conclusively localize the disorders

(Castillo, 1997; Gold & Gold, 2014; Greenberg, 2013). This alluded to mental illness being an effect that is based, deductively, on the notion that the brain is the causal agent of mental illness.

Therefore, psychiatry‘s entire foundation is based on tautological logic in that their findings cannot be grounded in anything except their own premises. This tradition continues today and has helped turn the pharmaceutical and psychiatric industrial complex into a multi-billion dollar empire (Frances, 2013; Greenberg, 2013).

DSM-IV: meta-analysis or cultural homogeny? Despite the initial success of the DSM-

III (and its subsequent revision, the DSM-III-R), it received a great deal of criticism from psychiatrists because it looked far too simplistic. Some psychiatrists felt that it degraded psychiatry since it was lacking in esoteric language – to the extent that ―clerks‖ could make diagnoses and openly criticize it (Greenberg, 2013, p. 41). Additionally, the millions of dollars spent on research to support biological determinism for the hundreds of different disorders – including schizophrenia and depression which are still accepted by many to be purely genetic and/or brain diseases – were inconclusive (Castillo, 1997; Marecek & Hare-Mustin, 2009;

Watters, 2010). Although many correlational studies showed some association between brain abnormalities and behaviour or emotion dysregulation, none of them were able to confirm causality (Castillo, 1997). Finally, cross-cultural researchers (e.g., Lee, 1995) were quick to criticize the APA for not acknowledging the role of culture in mental health. Therefore, it was in the best interests of the DSM Task Force to make these changes – with more ―science‖.

The Task force, according to Allen Frances, needed to find ways ―to protect the system from both instability and pontificating‖ (in Greenberg, 2013p. 47). So they did this by appealing to cross-cultural researchers by acknowledging the role of culture (Castillo, 1997) as well as to the psychoanalysts by acknowledging that insanity is only on the extreme of the personality spectrum while a whole other list of disorders that may not be seen in hospital settings (e.g., negativistic and depressive personality disorders) are also ‗out there‘ in ‗real life‘ (American

Psychiatric Association, 2014; Gold & Gold, 2014). As a result, while insurance-funded psychiatrists took dominion over ―psychoses‖ in the public hospital setting as well as globally, psychoanalysts primarily treated ―neuroses‖ in private practice (Dain, 1989; Gold & Gold,

2014). Therefore, before the psychiatric enterprise experienced more hostility, it managed to gain

positive recognition, while psychoanalysis became more profitable as it continued to gain lustre among the middle-to-upper class (Dain, 1989). Finally by the 1990s, there was enough national and global research available (again, based on the initial criteria of the DSM-III) that researchers could perform large-scale meta-analyses (Greenberg, 2013). In other words, those trained in advanced statistical methods could compile global data and homogenize any incongruences into predefined categories; in effect, multiple studies are treated as one large project:

We needed something that would leave it up to the tables rather than the people…

The idea was you would have to present evidence in tabular form that would be so

convincing it would jump up and grab people by the throats… We put a lot of

faith into meta-analysis [even though] I knew that the literature didn‘t have the

data. I knew we couldn‘t do a real meta-analysis of most of what would come up.

(Frances, in Greenberg, 2013, p. 47)

However, meta-analysis was a beautiful way to protect the APA because with such elaborate research designs and sophisticated tables, it was difficult to argue with them. The DSM

Task Force ordered psychiatrists to assign labels to what they thought they were observing in their patients and what they thought they were seeing on a global scale. Any significant overlap in symptoms between what looked like different clusters of psychiatric symptoms (e.g., depression and anxiety) was accounted for by comorbidity, while any ambiguity was protected by following with the label of not otherwise specified (Castillo, 1997; Gold & Gold, 2014;

Greenberg, 2013). What their 6-year effort led to was a 900 page DSM-IV in 1994 and a text revision, DSM-IV-TR in 2000, which made all previous editions look like pamphlets by comparison (American Psychological Association, 2014; Greenberg, 2013).

Owing to research in the past few decades that has demonstrated our brain plasticity, researchers critical of the biopsychosocial model (e.g., Castillo, 1997) have argued that any brain abnormalities could easily be the result of mental illness, rather than the cause of mental illness.

However, rather than rejecting the biopsychosocial model, the latest editions of the DSM have circumvented these findings (or lack thereof) by saying ―no laboratory findings that are diagnostic of [specific disorder] have been identified‖, including for depression and schizophrenia (Castillo, 1997, p. 10). Therefore, we can safely conclude that the American

Psychiatric Association has no intentions of rejecting the theory of biological determinism owing to the global power that it affords:

I know about the ―thought leader‖ issue first hand, because I used to be one

[owing to] my participation with the pharmaceutical industry… Many of the

thousand or more talks I have given over the years were financed directly or

indirectly by drug company money… And as chair of Psychiatry at Duke

University I presided over a department that had extensive industry sponsorship

for a number of its research and educational programs. (Frances, 2013, p. 94).

Frances (2013) also incorporated the Drug Company Hall of Shame (prepared by Raven, n.d.) in his best-selling book, Saving Normal, which lists some of the major lawsuits against pharmaceutical companies since 2004 as well as the amount they needed to pay in fines and settlements for selling or promoting drugs that were meant to cure mental disorders listed in the

DSM-IV-TR. These were for off-label promotions (i.e., promoting a product for a use that is has not been scientifically verified and approved federally), false advertising (e.g., deceptively suggesting that a drug can ‗cure‘ depression), failure to report safety data (i.e., precautions that

need to be taken while taking the drug), and more (p. 96). Forest Pharmaceuticals Inc., for instance, pleaded guilty for ―false claims‖ in 2010 for distributing an unapproved drug,

Levothroid, as well as for illegally promoting Celexa to treat depression in children and adolescents. They paid $313 million in fines and settlements. In January 2012 alone, the more renowned Johnson and Johnson paid $158 million for the off-label promotion and misrepresentation of safety for Risperdal – an atypical antipsychotic used to treat irritability in those diagnosed with schizophrenia, bipolar disorder, and autism. Three months later in April

2012, Johnson and Johnson were again sued for a whopping $1.1 billion, again for Risperdal – and this time for off-label promotion and fraudulent marketing tactics to children and the elderly.

However, this is generally considered ―chump change‖ and the ―cost of doing business‖ in comparison to the enormous profits that ―shady marketing practices‖ bring (Frances, 2013, p.

95).

Despite the large body of research that undermines the overall efficacy of psychotropic drug use, pharmaceutical companies do not shy away from selling a new diagnosis that will promote them, and doctors do not shy away from liberally prescribing them to millions of patients every year – including to children and the eldery who are extremely difficult to diagnose and also more vulnerable to their harmful side effects (Frances, 2013; Greenberg, 2013). For instance, the crucial turning point for ADHD drug sales in America was in 1997 when drug companies began buying more expensive medications and were simultaneously given the legal right to promote the drugs to parents, teachers and clinicians (Frances, 2013). By 2011, ADHD medication, along with antidepressants and antipsychotics alone made up approximately $40 billion dollars in revenue, or approximately 10% of the total revenue of all pharmaceutical drugs

(IMS Institute for Health Informatics, 2012). This was despite the fact that some of them –

particularly ‗atypical antipsychotics‘ such as Abilify, Risperdal, Seroquel and Zyprexa – which were rebranded as ‗mood stabilizers‘ (a slightly friendlier term), were associated with negative side effects such as tardive dyskinesia, diabetes, obesity, cataracts, and decreased life expectancy in children (Greenberg, 2013) as well as earlier mortality in the elderly (Epstein-Lubow &

Rosenzweig, 2010). If factors other than taking the drug (e.g., poor eating habits) are leading to reduced life expectancy, then physicians and psychiatrists are clearly not conducting proper assessments of their patients to find the underlying cause of their ‗bad behaviour‘ and ‗emotional dysregulation‘ – and it‘s not like the pharmaceutical companies are going to ask them to be more attentive. These negative side effects are merely considered occupational hazards because the profit gained from drug sales can go into funding research to hopefully, one day, confirm the theory of biological determinism.

DSM-5: everyone is mad!

Alice: ―But I don‘t want to go among mad people!‖ Cheshire cat: Oh, you can‘t help that. We‘re all mad here!

(Lewis Carroll, 1865/2009, p. 45)

The most recent DSM-5, published in 2013, hasn‘t changed much in terms of the number of pages and disorders, however it is more simplified than previous editions (American

Psychological Association, 2013; Gold & Gold, 2014; Greenberg, 2013). In other words, the disorders have been listed so broadly that virtually anyone can have a diagnosis. As Frances

(2013) summarized, if you like to over-indulge in some of your favourite foods, you have ―binge eating disorder‖; being slightly forgetful of your new coworkers names and faces because you‘re too engrossed in other priorities would give you the diagnosis of ―minor neurocognitive

disorder‖; losing a family member and going through the normal phases of grief and depression could mean you have ―major depressive disorder‖ – if the grief also affects your work and makes you easily distracted, emotionally dissociated, or a ‗space cadet‘, you also have ―adult attention deficit disorder‖ and need a combination of SSRIs and Ritalin; and if you have a daughter who has a temper tantrum, she‘s not just a little annoying anymore, she has ―temper dysregulation disorder‖ and possibly needs mood stabilizers.

The main reason behind this over-simplification is that the specificity of previous editions

(which psychiatrists initially fought for) contradicted far too many nuances in the real world – especially outside North America (Applbaum, 2006; Gold & Gold, 2014; Greenberg, 2013). For example, the theory that depression is caused by a lack of serotonin secretion has been heavily debated owing to research on the placebo effect, contradictory evidence, as well as inconclusive findings and straight out fraudulent research paid for by private pharmaceutical corporations, as we saw above (Frances, 2013; Healy, 1997; Kirsch & Sapirstein, 1998). Given how much of this research is available publically, the American Psychiatric Association is beginning to lose its members – and worse, its public trust, which was always shaky to begin with (Frances, 2013). A recent finding that is further reinforcing the criticisms against the psychiatric and pharmaceutical industrial complex is that in the U.S., 9% of school-aged children are diagnosed with ADHD, while the prevalence is less than .5% in France (Wedge, 2016). The main reason behind this discrepancy is that many physicians (including general practitioners) in the US and Canada (see

Miller, Lalonde, McGrail, & Armstrong, 2001), have a history of treating ADHD as a biological disorder, where its first line treatment is a psycho-stimulant, while psychotherapy, family therapy, or an overall assessment of the child‘s social context are recommended, but often secondary (Wedge, 2016). French clinicians, however, generally do not use the DSM (or the

ICD, for that matter); instead, they are trained to focus on psychosocial (e.g., parenting styles) as well as dietary causes of irritability, hyperactivity, mood fluctuations, and lack of concentration in children. While these ‗symptoms‘ point to ADHD in America, they generally point to a stressful or non-structured family environment as well as poor nutrition in France, and therefore require appropriate family counselling and/or lifestyle modifications rather than a lifetime of drug therapy (Wedge, 2016).

‗Delusions‘ are another classic example of how broad the DSM-5 categories are: delusions are defined as a symptom of psychosis whereby an individual has ―fixed beliefs that are not amendable to change in light of conflicting evidence‖ (American Psychological

Association, 2013). Given all the evidence that has contradicted biological reductionism over the past several decades, we can safely conclude that, under these criteria, that the APA itself, in practice, is delusional. Specifically, it appears to fall under the category of grandiose delusions.

According to Michael First, psychiatrist and text editor of the latest DSMs, the manual has become ―a victim of its own success‖ (quoted in Greenberg, 2013). First and Greenberg also admitted that they, like many other psychiatrists, ―don‘t care what the DSM‘s rules are‖ anymore:

Of the many adjustments I have had to make, diagnosing people in order to secure an

income was one of the strangest… I brought [my patients] in on the scam, explaining

what diagnosis I was giving them, sometimes even taking out the book and reading

the criteria and occasionally offering them a choice. But the fact that we were sharing

the lie didn‘t make our business any less dishonest. (Greenberg, 2013, p. 70).

Given the exposés on the psychiatric and pharmaceutical industries, another movement is underway by a growing body of critical social scientists, feminist scholars, psychiatrists themselves, anthropologists, and public media bloggers, who have labelled the psychiatric enterprise as ―pseudoscientific‖ (Whitley, 2012; p. 1039). Approximately a century of research and the billions of dollars accumulated from private pharmaceutical companies and publically funded agencies (such as the National Institute for Mental Health) in a vain attempt to reify the mind has primarily benefited those who receive a revenue share from drug sales (Greenberg,

2013; Frances, 2013). Ironically, this century-long project has been funded by the very people that they‘ve been claiming to treat and has done far more damage than restoration. One concrete example, which is discussed in the final chapter, is that of iatrogenic (physician-induced) deaths from psychotropic drug overdoses (Frances, 2013).

The first two chapters explored psychological and psychiatric theory, research, and practice in North America. The next chapter presents a more in-depth literature review of what happens when North American mental healthcare (or what has become of it) is applied in the non-Western world. After all, if highly powerful physicians and scholars such as Thomas Insel

(recent former director of the National Institute of Mental Health) and knighted Canadian psychiatrist Remi Quirion genuinely feel that ―psychiatry‘s impact on public health will require that mental disorders be understood as brain disorders‖, we can imagine what impact this has on developing countries who turn to North America to learn how to run their own mental healthcare systems (Gold & Gold, 2014, p. 51).

Chapter III. The International Politics of Mental Health Care

Human beings are naturally altruistic, curious, and socially conscious. What made humans unique as a species is our ability to communicate far more intelligibly that other animals. There are approximately 7,000 languages spoken today (Davis, 2009). This means that we, as a species, have 7,000 different cultures and 7,000 different ways of understanding the world. What this suggests, theoretically, is that even if you speak 10 different languages, you only have access to about .001% of the world‘s knowledge. Comprehending all 7,000 different social narratives and histories is not humanly possible, but understanding that this magnitude of variation exists is, at the very least, sobering. This is why we need to question how one culture and language has come to dominate our global meaning systems when the breadth of our knowledge is across 7,000 of them. ―When you lose a language‖, according to now deceased MIT linguist Kenneth Hale, ―you lose a culture, intellectual wealth, a work of art. It‘s like dropping a bomb on the Louvre‖ (in

Davis, 2009, p. 3).

Understanding what happens when Western cultures meet non-Western cultures is crucial for global mental health and health education because of the pre-eminence of Western thought

(Oyserman & Lee, 2008). Some even argue that Western cultural ideologies – which include ideas of the self, the other, and our overall health – are globally dominating the idea of what it means to be human (e.g., Applbaum, 1998; Kitanaka, 2006; Watters, 2010). To this end, the following sections will address: 1) how Western mental healthcare transcends international borders; 2) why we began experiencing a ‗global mental health epidemic‘; and 3) why current efforts to address this apparent rise in mental illness are, and will likely continue to be, unethical and unsuccessful.

Also included as part of this critique is a discussion of the World Health Organization‘s

(WHO, 2013a) recently published Mental Health Action Plan. Though well-intentioned and ambitious, the action plan is based on four rather erroneous assumptions. The first is that there is a global definition of mental health and illness; the second is that mental healthcare is synonymous with philanthropy; the third assumption, following the second assumption, is that mental health practice and advocacy can only have a positive global impact; and the fourth is that the evidence-based research that drives advocacy is valid. The purpose of the following sections is to review to literature that challenges these assumptions and demonstrates that, although some global mental health efforts can be useful for community restoration during a national crisis, there is also a much darker side to the discipline that is seldom addressed by mental health professionals, advocates, and, especially, the general public. Given that this research is relatively scant in mainstream psychological journals, I relied heavily on anthropological literature (e.g.,

Applbaum, 2006; Castillo, 1997; 2003; 2006; Kleinman, 1997; 2008; Gold & Gold, 2014;

Petryna, 2006; 2011; Young, 2008), as well as the work of Ethan Watters (2010) who thoroughly documented and deconstructed the mental health discourses in mainstream media, newspaper articles and scholarly journals by researchers and mental health professionals in his highly contentious and book, The Globalization of the American Psyche: Crazy like Us. Watters‘ (2010) work reads like a criminal exposé immersed in an ethnography and contains excerpts from his interviews with critically oriented mental health scholars and medical anthropologists from around the world, and was therefore a helpful guide to a large body of anthropological literature pertaining to the cross-cultural nuances of schizophrenia, eating disorders, posttraumatic stress disorder (PTSD), and depression.

The Assumption that we are Treating Brain Disorders

Clinical research, to this day, cannot clearly and conclusively support a purely biological etiology of mental disorders. Schizophrenia, autism-spectrum disorders (ASD), and Alzheimer‘s disease however, are often considered to be some of the most biologically driven owing to evidence of cortical dysfunction in patients who present overt symptoms (e.g., Frances, 2013;

Lopes, Soares, Coelho, & Figueiredo-Braga, 2015; Wang et al., 2015). Additionally a promising and inexpensive technology, called clustered regularly interspaced short palindromic repeats

(CRISPR, pronounced ―crisper‖) is being used to target the genes associated with heart conditions, cancer, HIV, and disease-carrying insects (e.g., Ledford, 2015): ―CRISPR is turning everything on its head‖ and ―causing a major upheaval in biomedical research‖. Therefore it is not surprising that it is also currently being used to assess whether we can alter or inactivate (i.e.,

―knockout‖) genetic mutations of various genes that are possibly associated with the phenotypic

(overt) expressions of schizophrenia, ASD and Alzheimer‘s disease (e.g., Miller, Gouvion,

Davidson, & Paulson, 2004; Wang et al., 2015).

Proponents of CRISPR are already warning that ―we should think carefully about how we are going to use [this] power‖. This warning, however, is being ignored by many clinicians and public health executives such as Thomas Insel, knighted Canadian psychiatrist and former director of the NIMH: ―current technology permits [the move] from clinical genetics to basic biology… permitting early detection and biological validation of mental disorders… If mental disorders can be understood as developmental brain disorders, we can develop critical insights into risk and resilience‖ (Insel, 2009, p. 132). Thomas Insel is a staunch supporter of biological determinism, even though he mentions the importance of an epigenetic approach – i.e., the effect

of environmental factors (nurture) on the phenotypic expression (nature) and prognosis of mental disorders. There is, however, no mention of what environmental factors can trigger and maintain mental disorders in individuals who may be genetically predisposed to them. Additionally, there doesn‘t appear to be a strong public incentive to address these environmental factors (such as relative inequality and social fragmentation, which are discussed later) among most mental health professionals and executives at pharmaceutical companies and public health organizations, as we will see throughout this thesis. Therefore, by diminishing the role of environmental factors and perpetuating the notion that we are treating purely medical disorders that may have some psychosocial components, the vast majority of the mental health industry is able to generalize mental disorders to all countries and therefore expand its reach and power. I will place heavier emphasis on some of the symptoms of schizophrenia for this section because it is often characterized as the most mysterious, perplexing and controversial DSM category owing to the evidence that supports both a biological and a social etiology.

There is growing consensus that culture and therefore language can shape an individual‘s subjective experience of an illness (Castillo, 1997; Kitanaka, 2006; Kleinman, 1997; Kleinman,

Kleinman & Lee, 1999; McGruder, 2002; 2004; Young, 2008). In the case of severe persecutory delusions, being convinced that CIA agents are following you and extracting your thoughts using sophisticated brain-imaging technology (though almost plausible in this day and age) would be characteristic of paranoia in urban American cities (Gold & Gold, 2014; Lake, 2008). Someone living in a rural village of East Africa or the Middle East, however, may feel that an evil spirit

(or jinn) has embodied them and is making them exhibit erratic and perhaps immoral behaviour

(Fakher El-Islam, 2008; Okasha, 1999). Prior to the industrial revolution, some delusions in

Europe were thought to involve animal magnetism where an individual would feel that animals

were capable of inserting thoughts into their minds, giving them unusual bodily sensations and making them exhibit abnormal behaviour (e.g., the case of Friedrich Krauss, in Gold & Gold,

2014, p. 67).

Delusions and paranoia can be found virtually everywhere and transcultural psychiatrists and medical anthropologists agree that while certain forms (e.g., thought insertion) of mental illness can remain relatively stable across cultures, their content (e.g., CIA versus jinn) can vary

(APA, 2013; Castillo, 1997; Gold & Gold, 2014; McGruder, 2002). Owing to these nuances, cultures are considered to be pathoplastic because an individual‘s subjective experience of an illness will vary depending on the social, cultural and linguistic narratives that are accessible to them at any given point of time (Gold & Gold, 2014; Stompe et al., 2006). Some psychiatrists have been documenting these cultural differences since as early as the 1960s (Zutt, 1967, as cited in Stompe et al., 2006) and the DSM-5 takes extra care in explicitly stating, throughout the manual, that ―an individual‘s cultural and religious background must be taken into account‖

(APA, 2013, p. 93) and that ―cultural and socioeconomic factors must be considered‖ since symptoms may be ―normative to the patient‘s subgroup‖ (APA, 2013, p. 103).

The DSM, however, discounts its own testimonies by utilizing the diagnostic codes (e.g.,

―V15.81‖ for ―Nonadherence to Medical Treatment‖, APA, 2013, p. 726) of the WHO and various U.S. health statistics bureaus (e.g., Centers for Disease Control [CDC]) to ensure

―consistent international recording‖ (emphasis added) of the prevalence of psychiatric disorders

(p. 103). In other words, cross-cultural mental health research (and therefore, practice) is merely given lip service in the DSM (Watters, 2010). Kleinmann (1997) argued that adding ―culture‖ to the DSM was more of a pyrrhic victory than an honest testament and a rather poor attempt to satisfy critics and cross-cultural researchers. Even in the most recent DSM-5 (APA, 2013),

cultural nuances are largely mentioned in the Appendix, therefore taking culture into account is almost optional and easily neglected in the case of making a diagnosis. Ultimately, the predominant themes in both the research and treatment of schizophrenia (and arguably all psychiatric diagnoses) attend to a more medical (i.e., genetic) and neurocognitive-driven model, without much thought to broader environmental factors that impact biological and psychosocial

(i.e., biopsychosocial) factors.

Predominant themes in research and rehabilitation. The general manifesto of research and rehabilitation for schizophrenia in North America (and now in many other parts of the world) was summarized by McGruder (2004). The patient‘s family (given they are supportive) is told that although full recovery is possible, chances are that the illness is permanent owing to the heightened activity and sensitivity of dopaminergic mechanisms in the central nervous system.

Brain imaging technology also confirms that patients suffer from increased ventricle size and decreased activity in the prefrontal cortex which explains the internal sensations, perceptions and overt behavioural manifestations of the disorder. However, just like insulin controls blood sugar levels in diabetic patients, antipsychotic medications regulate chemical imbalances in the brain to normalize behaviour and alleviate symptoms. Because everybody‘s body responds differently, the medication may not work or can pose some risks, but the patient can be monitored to ensure there are no negative side-effects. In the event that the patient feels too much discomfort, additional medication can be used to offset these symptoms. It is advisable for patients to treat schizophrenia like a chronic illness and the family should monitor the illness, be vigilant of abnormal behaviours and express understanding; that clinical researchers are doing everything they can to find the cure and assure that it is a top priority. In the meantime, this is the best they can do; it‘s not ideal, but it is much better than suffering the pain of a mental illness.

Most likely, if someone is diagnosed with schizophrenia, this is their rehabilitation protocol (McGruder, 2004). Evidence that schizophrenia is a brain disorder as well as the efficacy of this rehabilitaiton approach, however, has been debated if not criticized for decades

(e.g., Cohen, Patel, Thara, & Gureje, 2008; Gold & Gold, 2014; Hopper, 2007; McGruder, 2002;

2004; Sartorius et al., 1986; WHO, 1973; 1979, as cited in Castillo, 1997; van Os, Pedersen, &

Mortensen, 2004). Neuropsychological research demonstrates that abnormalities can be found in the prefrontal, parietal and visual cortices, hippocampus, amygdala, cerebellum, basal ganglia, and practically every other location of the brain, however there is a vast lack of consensus within these studies (Markota, Sin, Pantazopolous, Jonilionis, & Berretta, 2014; Silverstein & Keane,

2011; Watters, 2010). The assumption within these studies is that schizophrenia causes these changes whereas they might actually be a consequence of the disorder with as yet unknown etiology (as we will see later in this chapter, and Chapter VII, much of the evidence points to psychosis and possibly schizophrenia being a reaction to stressful circumstances in the sufferer‘s life).

Another interesting finding that often goes ignored is that psychopharmacotherapy does not significantly impact the symptoms of schizophrenia on a global scale, and none of the thousands of studies and billions of dollars spent on research (for schizophrenia alone) have found a single biological marker to confidently classify schizophrenia (Castillo, 2006; El-Badri

& Mellsop, 201; Knapp, Mangalore, & Simon, 2004; Lopes et al., 2015). Even with new advances in genomics (which, if successful, may wipe out psychopharmacotherapy as a first line of treatment for those who can afford more advanced care), it will not be as easy to trigger full- blown schizophrenia in a lab by altering the expression of genes that are possibly causing it, as it will be to alter genes related to the transmission of more biologically-based diseases such as

those caused by parasites (see Ledford, 2015). Finally, the fact that symptoms vary significantly in their frequency, prognosis, and treatment across different countries strongly undermines the theory that schizophrenia and its symptoms have a strong biological foundation, and suggest that social factors play a crucial role in its development (Castillo, 1997; 2003; 2003).

Schizophrenia: A Social and (Environ)mental Etiology

The theory that Eastern and African cultures have lower lifetime prevalence rates of mental disorders and better overall outcomes (particularly in terms of psychosis) became an axiom in cross-cultural research in the past five decades (Cohen et al., 2007; McGruder, 2002; 2004). This was extensively owing to large-scale longitudinal and multinational studies from the 1970s and

1980s that demonstrated that the prevalence, severity, and prognosis of schizophrenia, regardless of its sub-type, were far worse in economically developed countries (e.g., Sartorius et al., 1986;

WHO, 1973; 1979, as cited in Castillo, 1997). For instance, moderate to severe social impairment of schizophrenia was highest in countries such as the U.S. (56%) and lowest in less developed countries such as India (38%). Recent longitudinal research from the Netherlands also shows that the incidence of schizophrenia spectrum disorders is significantly higher in urban compared to rural areas within the same country (e.g., Sutterland et al., 2013; van Os, Pedersen,

& Mortensen, 2004). Some literature even suggests that full recovery is up to ten times higher among those who live in less developed, agrarian societies (Susser & Wanderling, 1994, as cited in Castillo, 1997). Ultimately, these researchers‘ commentaries all resonate with the critical (i.e.,

Marxist) argument that urbanization and industrialization can drive ‗abnormal‘ behaviour, and that the ‗dysfunctional‘ aspects of schizophrenia (and arguably many mental disorders) can be attributed to dysfunctional, or conflicted socio-political and economic system (Fox, 1978; Marx,

1906).

There are several explanations for how broader social factors can even influence the very emergence of a symptom in the first place (i.e., perhaps by triggering overt symptoms in those who may be genetically predisposed to a disorder). According to Castillo (1997), extreme delusions of grandeur (or milder forms such as narcissism and elitism) are more likely to be found in societies that are both individualistic (i.e., egocentric) and hierarchical such as North

America. They are, however, relatively non-existent in societies that are both collectivistic (i.e., sociocentric) and egalitarian such as the Senoi Temiar, who inhabit the Malaysian rainforest and place little to no importance on the ―self‖, as we understand the concept. The prognosis of schizophrenia, once it is diagnosed, has also been shown to be affected by cultural and familial factors. Some research demonstrates that high expressed emotion – whether the emotion invested is critical, hostile, or empathic – can drastically affect psychosis (Gómez‐de‐Regil, Kwapil, &

Barrantes-Vidal, 2014; Karno et al., 1987; Vaughn et al., 1992; Wig et al., 1987a; 1987b as cited in Castillo, 1997). Ironically, Anglo-American and British families – despite having the reputation of being largely ―individualistic‖, ―ego-centric‖ or ―stoic‖ (Oyserman, Coon, &

Kemmelmeier, 2002; Oyserman & Lee, 2008) – have also been shown to express intense emotion both towards themselves and others (Hooley, 1998). Among families that have a schizophrenic member, high expressed emotion was found in 67% of Anglo-American families,

48% among British families, while only 41% in Mexican and 23% among families in India

(Karno et al., 1987; Vaughn et al., 1992; Wig et al., 1987a; 1987b, as cited in Castillo, 1997).

A theory that broadly explains these discrepancies is that traditional beliefs common in

Eastern and African cultures tend to shift the focus of illness from the individual to an external deity (Castillo, 1997; Kitanaka, 2006). Within an industrialized environment, however, success and failure become common themes within the general political and cultural discourse; combined

with the notion of the ‗self‘, individuals are socialized to hold themselves personally accountable for success and failure (including in their ability to recover from mental illness) which can result in high expressed emotion in the face of perceived success and failure (Castillo, 1997; Hooley,

1998). According to Oyserman et al. (2002), there is some truth behind the popular stereotype that Anglo-Americans are, on average, more individualistic than other cultures; ―being an individualist is not only a good thing – it is a quintessentially American thing‖ (p. 3). However, it now appears that many developing countries have also begun to adopt this ideology as their socioeconomic and political system changes are driving and therefore beginning to echo the sociocultural changes that came about in the West as a result of their industrial revolution

(Cohen et al., 2008; Inglehart, 1997; 2000; Kleinman, 2008). Such changes include socially punishing those who do not adapt to the demands of a fast-paced capitalist environment. For instance, before the industrial revolution (arguably, since before the Middle Ages) families were responsible for building their own homes, forming their own communities, making their own clothes and finding their own food (Marx, 1906; McCubbin, 2009). Now, however, individuals have largely lost ‗the means of production‘ and are forced to adapt to the unnatural, market- imposed identities in which self-worth is dictated by worker productivity, material wealth or any other role that is otherwise ―unnatural‖ to our species when examining our evolutionary trajectory (McCubbin, 2009). Without adapting to these economic pressures, individuals have relatively little chance of having their basic needs met and therefore relatively little hope of retaining their sanity.

In his critical reflection of contemporary mental healthcare, McCubbin‘s (2009) also noted that in pre-modern thinking (which still exists in many societies) mental illness was related to external, spiritual forces and was beyond human understanding. Today, however, society

generally infantilizes individuals who are perceived to be ill. This may inadvertently increase the level of emotional reactivity towards them – particularly within the family environment, since individuals are now held accountable for their ability to recover. This has, effectively, become maladaptive, since high expressed emotion within a family system is one of the strongest predictors of poor prognosis of psychosis and many other mental health issues, regardless of culture (Gómez‐de‐Regil et al., 2014; Pourmand, Kavanagh, & Vaughan, 2005).

Kleinman (2008), who is a major figure in cross-cultural research and who felt that he initially reinforced the idea of the East-West dichotomy, is now echoing Cohen et al‘s (2008) concerns and arguing that sweeping generalizations and broad assumptions have become pointless because global capitalism has essentially put almost every society, including the United

States, in chaotic flux. We will find both sociocentric and egocentric orientations in virtually every geographic region, and we cannot, with any certainty, claim that Chinese cultures function in one way, or American cultures function in another way (Kleinman, 2008). Even though family ties appear to be strong while expressed emotion appears to be low in developing regions, many of them, including those of the Indian sub-continent and the Middle Eastern and North African

(MENA) regions (e.g., see Chapter 5 on Kuwait), are also hierarchical (specifically, patriarchal) in nature (Castillo, 1997). Therefore, while their cultures make families a source of strength and support, their sociopolitical structures can sometimes bleed into social interactions, making them equally distressing, and oftentimes oppressive (Castillo, 1997; Kleinman, 2008).

What is happening presently, is that biological determinism in mental illness is continuously, and simultaneously, being defended and discredited. Additionally, the protective cultural factors that exist in different parts of the world are beginning to crumble, making societies and therefore individuals more vulnerable to distress and thus different forms of erratic

behaviour. For these reasons, it is crucial to understand how the field of mental healthcare itself is implicated in this process, and how various cultures modify their existing explanations of illness with what is presented to them by some of the dominant Euro-American cultural mental health discourses. The following sections will address these changes using specific examples demonstrating how the prevalence of mental disorders increased in various non-Western countries.

Changing the Phenomenology of Self-Starvation in China

Between the 1980s and 1990s, South Asia experienced colossal socioeconomic growth which was amplified after Hong Kong‘s sovereignty, once under British rule, was handed over to China

(Kleinman et al.,1999). Hong Kong, Taiwan, and Singapore became international hubs of commerce; China became the third most powerful economy in the world and even sustained its global purchasing power after the 1997 market crash while the Japanese and Korean economies were on the verge of collapse (Kleinman et al., 1999). Owing to the political liberalization that followed military massacres of student-led protests in Beijing (The Tiananmen Massacre,

Calhoun, 1989), traditional ways of life began to wane. Kleinman et al (1999) described this period as ―a major transformation in how people [lived]‖ and demonstrated that it is impossible to construct one single narrative that can capture how individuals‘ perceptions of life and their everyday experiences changed (p. 2). Some of the most poignant cultural discourses, however, were explored by Dr Sing Lee, who is the aficionado and mental health expert on eating disorders in China. Lee helped China understand how ‗fat phobia‘, which never existed prior to political liberalization, was suddenly beginning to appear among young Chinese women

(Kleinman et al., 1999; Lee, 1995; Watters, 2010).

Assumptions Underlying Self-Starvation. Owing to the etiological complexity of self- starvation, it has been dissected within multiple academic disciplines such as psychology, psychiatry, anthropology, feminist theory and sociology (e.g., Cheney, 2011; Katzman & Lee,

1997; Le Grange, Louw, Breen & Katzman, 2004; Lee, 1995; 1996; Tavris, 1993; Thompson &

Hirschman, 1995). Scholars have analyzed the condition using both macro (i.e., sociopolitical) and micro (psychological) levels of analysis, however the core assumptions underlying eating disorders has consistently changed over time. Feminist scholars during the 1990s – who tended to have the most radical perspectives of the notion of body image – contended that female oppression, the imposition of contradictory roles for women, and the desire to be more

‗masculine‘ when entering the workforce caused body image issues (Cheney, 2011; Tavris,

1993). More recently, issues such as urbanization, immigration and ―Western acculturation‖ have been explored, and it is common to argue that Western media messages have infiltrated global perceptions of body image, causing ‗fat phobia‘ among women across the globe (Cheney,

2001; Le Grange et al., 2004). All these perspectives share the common theme that eating disorders are, regardless of sociological factors, induced by a societally-driven fear of fatness.

Even though some Western scholars have acknowledged that self-starvation can occur in the absence of fat-phobia, this theory is pervasive today and is still included in the most recent edition of the DSM (Lee, 1995; APA, 2013).

At least until the 1990s, however, Lee demonstrated that symptoms that could be classified as an eating disorder presented themselves very differently in China (Lee, 1995; 1996;

Lee, Lee, Ngai, Lee, & Wing, 2001). Chinese cultures traditionally valued curvier women; this paralleled the perspectives in the U.S. prior to women entering the workforce in the early 20th century and again after World War II until the 1960s (Lee, 1995; Tavris, 1993). However, the

British rule of China (after Margaret Thatcher‘s conservative party election in the 1970s) brought with it the Western fashion industry after which women supposedly began to idealize thin figures

(George, 1999; Katzman & Lee, 1997). Given the propensity for competition in Chinese culture

– especially in academic settings – as well as the cultural significance of food, the stage was set for adolescent girls to signal distress by refusing to eat. However, Lee (1995; 1996) noticed that

Chinese girls were resistant to these pressures and reasoned that other factors played a role in their self-starvation. In fact, his research demonstrates that unrequited love, emotional abandonment, or abuse were the primary drivers for appetite loss in China (Lee, 1995). Girls described the loss somatically; like pain, fullness, or tightness in the abdomen or esophagus (Lee,

1995).

Similar results were found in Germany in the early 1800s (Shorter, 1987; 1990); young women were not obsessed with food, looking thin, or ideals of beauty; rather, they manifested physical symptoms which generally led to poor appetite, food refusal and extremely unhealthy weight loss. Even up to the mid-20th century, there were barely any reports of fat phobia in

Western metropolitan cities such as Toronto, London, Berlin and Rome (Shorter, 1994, as cited in Lee, 1995; 1996). Additionally, contrary to the notion that women with eating disorders show discrepancies in their actual and perceived image (Hartman, Thomas, Wilson, & Wilhelm, 2013),

Chinese women‘s depictions of their bodies often matched how they looked and they usually wanted to reach their normal weight (Lee, 1995; 1996).

These findings were in sharp contrast to the DSM-III diagnosis of anorexia nervosa

(which was used as the gold standard at the time) as well as recent conceptualizations of anorexia and body dysmorphia in the U.S. (APA, 2013; Hartman et al., 2013). The narratives of the young

women in Lee‘s (1995; 1996) studies also contradicted the typical narratives of those with anorexia in North America, who often describe themselves as fat even when emaciated, and obsessed with their food intake (Cheney, 2011; Hartman et al., 2013; Lee, 1995). Additionally, fat phobia in the U.S. was initially predominant among high-achieving girls who came from privileged backgrounds (Cheney, 2011; Lee, 1996). Lee observed the opposite in China, where the girls were typically from low SES groups and were generally low-achievers who lived in rural villages rather than the greater metropolitan areas where Western media messages were more prominent (Lee, 1995, 1996).

Tipping points for cultural change. The case that acted as a turning point in China was that of Charlene, who was a psychiatric patient turned public media figure after her death

(Watters, 2010). Charlene collapsed weighing 75 pounds on a busy metropolitan street in Hong

Kong in 1994, and therefore caught the public‘s eye at a time where the ‗fear of fatness‘ was not even available as a cultural discourse. Because her case was made popular by the tabloids with labels such as ―Girl Who Died in Street was a Walking Skeleton‖ and ―Schoolgirl Falls Dead on

Street: Thinner than a Yellow Flower‖ (Watters, 2010, pp. 42-43), doctors in China were desperate to find an explanation for her yan shi zheng (meaning ―the disorder of loathing to eat‖ in both Cantonese and Mandarin; Watters, 2010, p. 43). Therefore, they turned to Western experts to make sense of why a young girl would literally starve herself to death.

Within weeks, tabloid messages in China began associating the DSM notion of anorexia to celebrities and the beauty industry, and Charlene‘s community began running public health campaigns to increase awareness about self-starvation (Watters, 2010). Consequently, screening for anorexia in school settings and Western-style counseling programs such as Kids Everywhere

Like You (KELY) became commonplace in China (Watters, 2010). By 1997, just three years after Charlene‘s death and the adoption of the DSM-III by Chinese psychiatrists, local experiences of self-starvation began to wane (Lee, Ng, Kwok, & Fung, 2010; Ngai, Lee, & Lee,

2000). Around the same time that Lee (1995; 1996) tried to educate China on indigenous descriptions, many young women, or the ―me too‖ anorexics, already began presenting with the same explanations for self-starvation as women in the United States (Lee et al., 2010; Ngai et al.,

2000; Watters, 2010). By 2007, Lee found that anorexia in Hong Kong almost perfectly matched what was seen in the West (Lee et al., 2010). For instance, there were twice as many cases of eating disorders in the early 2000s compared to 1990s predominantly among young, single women, who began physically and emotionally manifesting the same symptoms as women in the

United States. Although the overall frequency of anorexia remained relatively stable, there was also an increase in the proportion of fat phobic women with anorexia and bulimia at every three- year interval between 1987 and 2007 (Lee at al., 2010). This was an almost exact replica of the epidemiological trends of eating disorders in the West after diagnostic criteria bled into their cultural narrative; the only difference is that China was over a decade behind (Currin, Schmidt,

Treasure & Jick, 2005; Lee et al., 2010).

This phenomenon of changing epidemiological trends was also observed in the U.S., after

Karen Carpenter died in 1983 of heart failure, supposedly from anorexia (Watters, 2010). Within the next decade, the numbers of scholarly and media articles on anorexia proliferated and by the late 1980s, young women in the U.S. began presenting with the same symptoms of anorexia. It was officially in the ‗symptom pool‘, not unlike hysteria which rose after its codification in the late 1800s and declined again decades later (Shorter, 1986; Waters, 2010). By the 1980s, anorexia began ―luring another generation of women‖ from privileged backgrounds (Watters,

2010, p. 34). Similar results were found by Currin et al. (2005) with bulimia in the U.K after

Princess Diana publically announced her struggle with the disorder. This inadvertently glamorized bulimia; all of a sudden, after her case become common public knowledge in 1992, the incidence of bulimia rose and then declined again in 1997 after her death (Currin et al., 2005;

Watters, 2010).

These patterns, along with Charlene‘s case and additional longitudinal case studies of anorexia in China, led to the argument that the phenomenology of self-starvation is historically mutable (Ngai et al., 2000; Lee et al., 2010; Watters, 2010). In other words, not only do women‘s explanations of self-starvation (i.e., non-fat phobic to fat phobic) change over time, but the subjective experiences of the illness are transformed, depending on the cultural discourses that are available to the public. Therefore, the notion of ‗culture-bound‘ symptoms are dissipating in the case of anorexia and bulimia which are now found in virtually every society (Cheney, 2011;

Lee, 1996; Lee et al., 2010; Watters, 2010). Additionally, the theory that the ideal for thinness is solely attributable to Western media has also been challenged. In China, women who were exposed to Western media rarely showed signs of fat-phobia, until anorexia made its way into their cultural narrative (Lee et al., 2010). This suggests, according to Shorter and Keefe (1994, as cited in Watters, 2010), that individuals will unequivocally choose to explain psychological and physiological symptoms (in light of dominant cultural narratives) that were previously difficult to articulate. Therefore, rather than engaging in a process of ‗discovery‘, societies are likely participating in a collective phenomenological construction of illness using a shared globalized language that was previously unavailable to them. This language, in turn, is capable of changing the lived experience of illness, especially among adolescents and young adults (see Illness

Negotiation as a Political Process later in this chapter).

The next section discusses what happens when mental healthcare comes face-to-face with a society that is less accepting and shows resistance (and sometimes contempt) towards Euro-

American definitions of mental illness. Nothing can shake Psychology‘s security more than when it enters a danger zone in the non-Western world. It is during this time, when the discipline itself is under distress, that we can explicitly watch how its principles of surveillance, prediction, manipulation and control unfold.

Parachute Therapists in Disaster Zones

The day after Christmas in 2004, a major tsunami tore through Indonesia, Thailand,

Malaysia, coastal India, Sri Lanka, and other countries across the Indian Ocean, killing almost three-hundred thousand and leaving about five million people homeless (―US presidents in tsunami aid‖, 2005; Watters, 2010). Among the survivors was a woman named Debra Wentz, current director of the New Jersey Association of Mental Health Agencies who happened to be in

Galle, Sri Lanka at the time of the event (Watters, 2010). Although Wentz is not a clinician, based on her observations of the September 11th attack in the United States, as well as decades of accumulated research on post-traumatic stress disorder (PTSD), Wentz (2005) immediately forecasted a high prevalence of ―staggering acute and long-term mental health needs‖ (p. 5). She called the prime minister of Sri Lanka and recommended devising a plan to locate and treat survivors of the disaster, and even advised, on local television, that parents should ―stay alert to the signs of depression and [PTSD]‖ and that ―mental illness should bear no shame‖ (p. 5).

Similarly, Jonathan Davidson from Duke University predicted that mental illness would ―reduce quality of life and prolong human suffering‖ among survivors (Davidson, 2006, p. 3). Wentz also helped create the Tsunami Mental Health Relief Fund which brought a tidal wave of mental

health professionals, researchers, and volunteers to help treat survivors and train local counselors in Sri Lanka to provide ‗appropriate‘ mental health care (Watters, 2010; Wentz, 2005, p. 5).

Within weeks, aid from the United States, England, France, Australia and New Zealand began pouring into Sri Lanka (Watters, 2010). Since America‘s identity as the ‗global saviour‘ has been built by meeting ―great humanitarian challenges‖ and ―providing hope to suffering people‖ (Bush, 2005, in ―US support for earthquake and tsunami victims‖), George W. Bush along with former presidents Bush and Clinton came together and sought an almost 100 million dollar budget for the United States Agencies for International Development (USAID) to help reconstruct the infrastructure in Sri Lanka and neighboring regions. Almost 20% of these funds were allocated towards community building and psychosocial relief (Bush, 2005). Australia also sanctioned an approximately 800 million U.S. dollar budget to the tsunami relief fund, a portion of which was to help Sri Lanka construct a mental health care system, which was, according to the director of AusAid, difficult ―because there was nothing much there before‖ (Robin Davies, in Watters, 2010, p. 70). This acted as an open invitation to mental health professionals and advocates from Western nations to tear through various disaster zones and provide psychological first aid and help build a mental health care system from the ground up.

Recruiting mental health advocates. Since posttraumatic stress disorder (PTSD) was added to the DSM in 1980, by the 1990s, PTSD research was ―where the action was‖ (Watters,

2010, p. 72). By the time of the 2004 tsunami, there were over 20,000 publications on PTSD.

Katie Amatruda, Californian Board Certified Expert in Traumatic Stress (BCETS) built her career by recruiting and training therapists and volunteers in post-disaster crisis intervention and is one of thousands of therapists who propagates PTSD into the cross-cultural narrative (Watters,

2010). Amatruda‘s name carries several other credentials, such as LMFT (Licensed Marriage and

Family Therapist), EMT (Emergency Medical Technician), DMAT (Disaster Medical Assistance

Team) and leads the Red Cross Disaster Service Mental Health Team (DSHR), and is also a diplomat with the American Academy of Experts in Traumatic Stress (National Center for Crisis

Management [NCCM], 2013). To this day, Amatruda dedicates her time recruiting mental health volunteers and advocates from the United States through various ad campaigns. In Play Therapy

Magazine, one of her slogans is, ―want to go to exotic (and sometimes not so exotic) places?

Become a disaster mental health volunteer with the Red Cross!‖ (NCCM, 2013). Amatruda even authored A Field Guide to Disaster Mental Health: The Very Big Wave and the Mean Old Storm whose slogan reads, ―welcome to chaos!‖ and is designed to provide coping skills to professionals, volunteers, and survivors after a disaster (Amatruda, n.d). This manual is approved by a plethora of board-certified mental health, social work, and nursing institutions in the United

States such as The Board of Registered Nursing and the Florida Board of Clinical Social Work and the National Board for Certified Counselors.

Needless to say, mental health professionals and volunteers began pouring into various disaster zones in South Asia; some described them as ‗parachute counselors‘, who landed briefly to set up mental health camps (Ganesan, 2006; Watters, 2010). Ironically, many of the mental health professionals, advocates, and volunteers found it difficult to cope with the aftermath of the disaster. They found themselves in constant debriefing sessions with each other, while the local children – particularly in Sri Lanka – appeared nonchalant about all the chaos that surrounded them (Summerfield, 2006; Watters, 2010). In fact, local survivors generally expressed reluctance to discuss the disaster with foreign experts (Ganesan, 2006; Summerfield, 2006). Some professionals and reporters even expressed shock at how young survivors were cheerful and eager to go back to school after witnessing multiple deaths; that they were ―clearly in denial‖ and

―it‘s only a matter of time‖ before their resilience crumbles (Summerfield, 2006, p. 255; Watters,

2010, p. 77).

Mental health advocates: retaliating against resistance? Considering that Sri Lanka was already reeling from a civil war after which a ―fragile peace‖ was set in place (Ganesan, 2006, p.

241), life threatening situations were not foreign to locals. In fact, even survivors who felt that their lives were in danger weren‘t particularly traumatized but instead felt that they had an internal reservoir of resilience which they gained through their friends, family, and religious communities (Hollifield et al., 2008). Similar results were found through qualitative studies in

South India, which suggest that this ―strong social capital‖ acts as a protective barrier to the trauma that is commonly expected after life-threatening adversity (Aldrich, 2011; Rajkumar,

Premkumar, & Tharyan, 2008). Given this resistance, there was little room for formal mental health care. In effect, the disaster zone became an allegory of the stereotypical psychological laboratory in which psychologists could not control for extraneous or confounding variables.

Their predictions of how survivors should have acted were not supported, therefore survivors did not afford the utilization of crisis management skills that some international therapists and advocates were so proud of and eager to use. Essentially, unless the members of a society are traumatized, the power of mental health care can be relatively futile. The only people who were

‗traumatized‘ in the Western mode following from definitions of PTSD were, interestingly, the parachute counsellors.

According to Young (2008), it just seems like common sense that everyone, irrespective of culture, will have the same psychological response to traumatic events and that it is almost impossible for many mental health professionals and advocates to think otherwise. Nevertheless, there were clearly early signs of disparity between the Euro-American expectations of trauma

and the actual responses among survivors. Cognizant of the zealousness of mental health advocates, local university professors in Colombo began warning various agencies that ―disaster zones attract trauma and counseling projects‖ and pleaded with international disaster specialists to not treat the population like emotional casualties (Ganesan, 2006; Watters, 2010, p. 76).

Despite their efforts, the more ―mainstream‖ definitions of self and healing were often imposed on the population because of the assumption that survivors ―must‖ develop internal psychic turmoil (Summerfield, 2006; von Peter, 2008, p. 640). To this end, many survivors were gathered for what looked like mandatory counseling, and reports claimed that up to 70% of children suffered from PTSD (Summerfield, 2006). Within weeks, Sri Lanka witnessed a hegemonic form of psychiatry bleed into all mental health practice and promoted a homogenous cultural perception of trauma that effectively undermined the resilience of local survivors (Summerfield,

2006; von Peter, 2008; Watters, 2010; Young, 2008). Essentially, what Summerfield (2006), von

Peter (2008) and Watters (2010) argued was that it was not the natural disaster per se, but many of the foreign mental health providers and their foreign ideas and concepts that contributed to the trauma.

Suffice it to say, the approach that post-tsunami disaster mental health experts and PTSD advocates took came under considerable scrutiny. Critics argued that mental health advocates were so eager to reinforce the agency of their discipline that their voice of reason began to silence the collective cultural discourse of resistance among survivors (von Peter, 2008;

Summerfield, 2006; 2010). Some said that the rush towards providing 80ounselling in disaster zones resembled the chaos in an emergency room and that early 80ounselling was seen as ―the psychological equivalent of applying clean dressing to fresh wounds‖ (Ganesan, 2006; Watters,

2010, p. 76). Since psychological first aid was met with the frenzy of draining ‗psychic

infection‘, many mental health advocates didn‘t even attempt to understand indigenous methods of coping (Ganesan, 2006; von Peter, 2008; Watters, 2010).

Some mental health representatives of the WHO, such as Shekhar Saxena, were appalled at the way many psychologists and psychiatrists directed the course of action at emerging mental health camps (Watters, 2010). Other local observers expressed both contempt and gratitude; for instance, Mahesan Ganesan, who is a local psychiatrist in Batticaloa, admitted that some of the efforts were especially helpful. Ganesan (2006) noticed that some aid workers approached local communities and asked them to prioritize their needs for food, shelter, and medical aid and quickly set about getting their needs met in the order that they were requested. The PTSD and counselling teams, however, rarely consulted with the local communities; even foreign social workers became more interested in individual and group 81ounselling than working with local administrative services. In fact, Ganesan noticed that various mental health camps became territorial with the populations they were helping and began sanctioning communities instead of working together to bridge the gaps that the tsunami left behind. He also noted that some experts merely set up projects, briefly trained local 81ounselling in data collection methods and therapeutic approaches that they thought were most appropriate, and quickly migrated to other disaster zones.

Ganesan (2006) appeared confused about why some mental health agencies were pontificating. However, based on the dozens of publications that appeared in European and

American journals and the hundreds of researchers who authored papers on post-tsunami trauma

(e.g., Holifield et al., 2008; Kristensen, Weisæth, & Heir, 2009; Kumar et al., 2007; Ruf et al.,

2010; Ranasinghe & Levy, 2007), it appears that disaster zones were transformed into data collection sites. Large scale quantitative studies began resembling the census studies that were

carried out after the wars in the U.S. Other studies began resembling those that attempted to validate the existence of psychiatric disorders during the DSM‘s early years (see Chapters I &

II). For instance, some researchers adopted the Harvard Trauma Questionnaire to identify and predict PTSD using complex mathematical algorithms in a coastal village in India (e.g., Kumar et al., 2007). Other researchers looked at the prevalence of PTSD, depression and anxiety after the tsunami (Hollifield et al., 2008) and sex disparities in mental disorders (Ranasinge & Levy,

2007). Some psychological interventions were even tested on traumatized children in tsunami- affected areas (Neuner et al, 2008; Ruf et al., 2010). Finally, researchers also attempted to cross- culturally validate potential diagnoses, such as Prolonged Grief Disorder, for the DSM-5, because they noticed that some individuals were mourning the loss of their families a bit longer than what may be considered normal in the Western world (Kristensen et al., 2009).

Ganesan (2006) recognized that some of these practitioners and researchers were well- meaning, however many came in ―without any prior communication or invitation‖ (p. 243) and used local taxi drivers as translators for brief 82ounselling sessions and questionnaires that they were validating. This apparently caused far more damage than help because of the rivalry that began ensuing within the organizations themselves. Many of research projects were carried out with local practitioners who began collaborating with foreign agencies and even competed with local partner organizations and reduced the amount of practical work they were doing with families (Ganesan, 2006). Because of the economic burden that follows natural disasters, it was difficult to resist the monetary benefits that came from international organizations. As the power of these international agencies began resembling the power of the census bureau after the wars in the U.S (Danziger, 1994; Greenberg, 2014), local practitioners began following in the same footsteps as many psychologists and psychiatrists during the industrial era in the U.S. who were

now beginning to compete for status. In effect, ―this completely changed the character of these

[local] organizations very rapidly‖ and made them weaker (Ganesan, 2006, p. 244).

Glorified martyrdom. The mask of appearing ―socially relevant‖ in order to get state- approved funding is nothing new to the disciplines of psychology and psychiatry (Danziger,

1994; Reicher, 1996). Although the intentions of international agencies can be genuine, there is also a sense of glorified martyrdom that is seldom explored openly in the mental health field

(unless of course psychologists are studying suicide bombers; e.g., Post, 2009). For instance,

Katie Amatruda insists that her work is meaningful and culturally sensitive (Amatruda, 2005, in

―A Visit to Sri Lanka‖). She discussed how the ‗hyper-empathy‘ and ‗extrasensory radar‘ that many mental health professionals feel is a gift to those they touch emotionally (in Watters,

2010). Given the list of credentials that follow her name and the fact that she‘s considered to be a well-known ‗dynamic speaker‘ who runs anti-stigma campaigns, it is worrisome that her profile on the National Center for Crisis Management (NCCM, 2013) also advertises for Pfizer, Zoloft, and Drugs.com. Additionally, the association lures mental health advocates with Grand Lux

Vacations directly on their website. Needless to say, Reicher (1996) was not aimlessly criticizing psychology when he said that it can often be self-aggrandizing and driven by power. Similarly,

Greenberg (2014) and Watters (2010) were not simply overestimating the role of pharmaceutical giants in funding mental health campaigns; it is quite clear that the many (if not the majority) of international mental health and anti-stigma campaigns are driven by the prestige of martyrdom and funded by Euro-American pharmaceutical companies who will help propagate buzz words like ‗mental health‘ into a cultural narrative as an entrée to their chemical products.

On a humorous note, Amatruda‘s online Supervisor’s Journal has a superhero cartoon and a Superman logo next to the training module index for clinical supervisors, which she is

apparently certified to teach, including by the National Association for Social Workers

(Amatruda, n.d., ―A Supervisor‘s Journal‖). This, along with Amatruda‘s notion of ‗extrasensory radar‘ further demonstrates the often false sense of heroism that plagues Western mental health practice (see Orange, 2001). To give another example, the International Trauma Treatment

Program Director, Dr. Van Eenwyk, claimed that the clinician‘s job is quite similar to that of the wizard from Wizard of Oz: to ―reveal ourselves as the man behind the curtain‖. Cognizant of the criticisms that the mental health profession was receiving, Eenwyk said, ―We don‘t indoctrinate.

We empower‖ (in Watters, 2010, p. 95). It is becoming more and more obvious that some clinicians can be – despite their elite credentials – ‗quack‘ in nature and practice. The United

States (in contradistinction to most European states) seems to be smitten with methaphors of superheroes, magical thinking, and idealism, and these discursive allegories are obviously going to become a central discursive resource for understanding themselves and their world. Although this is not an issue in and of itself, it can be quite harmful in its mass practical applications.

This chapter will not be complete without discussing the bioethics of transnational psychopharmacotherapy, which has become a critical component in global mental healthcare. I do this by exploring the ethnographies of global mental health conventions as well as the narratives of ‗Big Pharma‘ executives and marketers. Anthropologists such as Arthur Kleinman,

Laurence Kirmayer, Kalman Applbaum, and Adriana Petryna have dedicated considerable amounts of time educating scholars on how the mental health discipline and pharmaceutical drug marketers can oftentimes misuse clinical and cross-cultural research to manipulate an entire generation‘s sense of self. The majority of insights in the following sections have been drawn from their work, which are as much ethnographic analyses as they are bioethical testimonies.

The Bioethics of Transnational Psychopharmacotherapy

This section is about how human suffering affords a bourgeoisified notion of human salvation.

Rather than relying primarily on critical (and some might comment, disgruntled) psychologists and psychiatrists (e.g., Healy, 2006; Greenberg, 2013; Frances, 2013), I have also drawn on the works of cross-cultural mental health researchers (e.g., Krimayer, 2002; Petryna & Kleinman,

2006; Kitanaka, 2006), anthropologists (Applbaum, 2004; 2006), and other critical thinkers (e.g.,

Saul, 2009) whose voices and warnings about the mass-marketing of healthcare across Western borders have often been silenced. In some cases, their insights into other cultures‘ concepts of self and meaning have actually been used to transform an entire nations‘s perception of health and well-being. This happens as part of a global neo-liberal movement by combining cultural metaphors of wellbeing and Euro-American mental healthcare to a market-driven view of human agency (Saul, 2009). Neo-liberalism (also known as neo-conservatism or economic conservatism) is based on Friedman economics which forces deregulation, strengthens privatization and eventually weakens governments (Saul, 2009). In healthcare, neo-liberalism essentially promotes what appears to be ‗free consumer choice‘ even though the information that is marketed to the public is partial towards the consumption of products that benefit private corporations (Applbaum, 2004; Saul, 2009).

I will begin by discussing the work of an anthropologist named Kalman Applbaum who specializes in the ethnography of mental health conventions, symposiums, board meetings, and other ball-room soirées. In his highly satirical and candid commentary on the World Psychiatric

Association (WPA) meeting in Yokohama, Japan, Applbaum (2004) described the luxuries, gourmet meals, well dressed hosts, and virtual reality simulators that allowed health professionals to view the world from the eyes of their schizophrenic patients. The most cordial

aspect of this event was that the entire trip was funded – not by local medical or academic institutions, but by pharmaceutical giant, GlaxoSmithKline (formerly known as SmithKline

Beecham).

It is very common for some psychiatrists (and other physicians) to accept bribes, or, euphemistically, experience ‗financial conflicts of interests‘ (FCOIs) with the DSM or pharmaceutical company executives (Cosgrove et al., 2014; ―Fierce Pharma‖, 2014). Even when this bribery was publicly exposed over the last two decades, the American Psychiatric

Association stated that practitioners were only allowed to accept $10,000 per year from pharmaceutical companies (Greenberg, 2013). Therefore, the APA has apparently normalized and accepted bribery as a legitimate and ethical transaction in healthcare. When Applbaum

(2004) questioned the psychiatrists at the World Psychiatric Association conference in Japan, they generally felt that, owing to their years of expertise and critical capacity, they were unaffected by the subtle persuasions of pharmaceutical executives. As one psychiatrist said, ―I‘m probably a heck of a lot smarter than the marketers at any drug company‖ (p. 304). (Obviously, he hasn‘t read the research regarding the effectiveness of such advertising strategies).

The issue with this line of thought is that it assumes individuals are capable of making rational decisions given our supposedly unrestricted access to information (Saul, 2009). As

Applbaum (2004) and other critics (e.g., Healy, 2006; Petryna & Kleinman, 2006; Saul, 2009) have argued, we assume that others, like ourselves, act within a consumer choice model. By propagating the notion of ‗free will‘, private corporations have essentially given practitioners and patients a false sense of agency – or what Marx called, a false consciousness (see Chapter I).

Owing to the overarching influence of the biopsychosocial model on a global level (e.g., WHO,

2013), the voices of more vigilant mental healthcare providers and critics have generally been

silenced. In effect, the information about mental health and wellness that is offered to – or rather imposed on – international key stakeholders in the mental health domain is not, in fact, unfettered (Applbaum, 2004).

The mega-marketing of antidepressants is one of the best success stories of psychiatry in the past six decades (Frances, 2013; Greenberg, 2013; Healy, 2006; Kirmayer, 2002). The introduction of Prozac (an SSRI) in the 1980s was considered to be a great advance in medicine since it (supposedly) had very few side effects, even though its efficacy was relatively low

(Healy, 2003; Kirmayer, 2002). In fact, the promotion of fewer side-effects was just another falsity (Frances, 2013). Despite the lack of conclusive evidence to support the global effectiveness of psychotropic medications, their total revenue exceeded $18 billion per year by

2012; almost 70% of this revenue came from SSRIs alone (Frances, 2013, p. 89).

Given the exponential growth of pharmaceutical sales over the last several decades, there are now two fundamental questions concerning the bioethics of transnational psychopharmacotherapy (Applbaum, 2006). The first is whether globally launching prescription psychoactive drugs (such as antipsychotics and antidepressants) to treat mental disorders represents an advancement in healthcare, or whether it reflects a market expansion. Regardless of which outcome is accurate, the second calls into question the importance of the congruence between medical, commercial, and ethical discourses. The executives at psychopharmaceutical drug manufacturing companies and their drug marketers (herein referred to as ―Big Pharma‖), physicians (i.e., psychiatrists and primary care doctors), as well as some non-medical mental health professionals and also laypersons, can often take overly optimistic view of the advancement of healthcare (Applbaum, 2006). By grouping mental disorders with other ―chronic illnesses‖ such as multiple sclerosis and rheumatoid arthritis (e.g., Carder, Vuckovic, & Green,

2003), clinicians generally view the progression of psychopharmacotherapy in the same light as medical advances in the areas of oncology, orthopaedics, and the study of infectious diseases and vaccinology (Applbaum, 2006; Greenberg, 2013). Even the World Health Organization views

―mental and behavioural disorders‖ in the same light as chronic ―noncommunicable diseases‖ such as diabetes, cardiovascular diseases, and cancer (WHO, 2013a, p. 6; 2015,

Noncommunicable Diseases Factsheet, para 2).

Countries in which the general population is aware of, and accepts the presumed innate causes of mental disorders and their treatments, are considered to have high ―mental health literacy‖ (Jorm, 2012). Similarly, countries that consent to, and promote psychopharmacotherapy within their nexus of medical and mental healthcare are considered to have an ‗enlightened healthcare policy‘ (Applbaum, 2006, p. 85). Both of these perceptions are critiqued in this section. Critics such as Kalman Applbaum (2004; 2006; 2010), Gary Greenberg (2013),

Laurence Kirmayer (2002; 2006), David Healy (2006), and Adriana Petryna (2006; 2011) collectively agree that Big Pharma, psychiatrists and the general public form, according to

Applbaum (2006), a ‗triple backing of support‘ for this so-called ‗advancement‘ in healthcare.

They reason, however, that the widespread use of psychopharmacotherapy reflects a corporate- driven strategy, and that healthcare, in this respect, has not actually improved; it has merely expanded and destructively shaped an entire generation‘s sense of self: a self that is commensurable to the needs and profit motivations of Western hegemony.

Applbaum‘s (2006), Labri‘s (2014) and Saul‘s (2009) analyses highlight several factors that shape the advancement of global psychopharmacology. In the United States, the most critical factor is that pharmaceutical companies and biotechnology firms are private, for-profit institutions who both fund and conduct 90% of the research that goes into approving a new drug,

while public-funded university researchers largely generate the knowledge that contributes to the understanding of the etiology and outcomes of a medical condition (Labri, 2014). Given that pharmaceutical companies (which include their researchers, manufacturers, marketers, and executives) are private, their revenues are contingent upon competition with other pharmaceutical companies therefore the only way to increase profit once drug sales have plateaued (or saturated) in their respective countries of origin is to expand sales in other countries (Applbaum, 2006; Saul, 2009). Additionally, the fixed cost of developing drugs almost tripled between the 1980s to 2000, therefore Big Pharma (which again refers to the whole pharmaceutical industrial complex, but particularly to individuals who make the executive decisions within them) needed to expand to global markets in order to offset these costs and drive higher profits. Finally, by increasing foreign physicians‘ ―awareness‖ of advanced medicine in the U.S., the disparity in healthcare practices between Western and non-Western countries diminishes. This means that the number of healthcare environments that are conducive to conducting business increase as foreign agencies and corporations proselytize their version of

―truth‖ in a wholesale successful attempt in what is, arguably, cultural imperialism through the propagation of Western modernization ideals with ―science‖ as lure.

There are several companies that provide marketing insights to pharmaceutical companies; the two I‘m going to focus on are IMShealth, who provides global marketing insight to Big

Pharma, as well as PhRMA (Pharmaceuticals Research and Manufacturers of America), who globally advocates for American pharmaceuticals (Applbaum, 2006). We can first turn to

IMShealth as a good example of how modernization is used to drive pharmaceutical sales (see

IMShealth, 2015). Since 1954, IMShealth has been providing marketing strategies to, and liaises between Big Pharma, public health agencies and policymakers in over 100 countries, and

therefore bridges the gaps between the corporate sector and public health on a global scale

(IMShealth, ―Company History‖, 2015). Some of IMShealth‘s clients include GlaxoSmithKlein and Pfizer, who are the manufacturers and distributors of Paxil and Prozac, respectively

(IMShealth, 2015). Some of their commentaries include Localizing Your Sales Strategy with

Mobile Sales to target specific populations and Pharma Should Make Better Use of Social Media to Engage Patients and Improve the Use of Medicines (IMShealth, 2015). Additionally, How

Social Media Intelligence is Strengthening Pharma Strategy is one of many of the other dozens of commentaries that explain how social media research has been exploited:

Now, with upwards of six billion mobile subscriptions worldwide [and] well

over one billion Facebook users… social media is no longer a curiosity to be

observed from the sidelines, but a powerful source of online intelligence that can

be used to drive more responsive engagement with customers, direct future

strategy, and maintain compliance (IMShealth, 2015, p. 2).

Modernization: changing the meaning of well-being. Although the industrial revolution first occurred in Europe and North America, Inglehart (1997) argues that the advancement of technology and industry are not particularly ‗Western‘ per se. Neither is bureaucracy. In fact,

China was the leading bureaucratic nation in the 17th century, and prior to the industrial revolution, Europe learned mathematics from India and Egypt (Inglehart, 1997). However, given that modernization first appeared in the West, Western societies – particularly the United States

– are used as benchmarks for advancement in developing countries. Statements such as ―Japan is five years ahead of China‖ or ―fifteen years behind‖ America become commonplace among foreign governments (Applbaum, 2006, p. 101). This ‗modernization syndrome‘ – which includes urbanization, rapid technological innovation, and increased (or reinforced) bureaucracy,

become the pitfalls of any developing society (Inglehart, 1997; 2000; Saul, 2009). This is especially true when they are followed by income inequality, oppression, and exploitation – which are more often than not the case worldwide (Buckley, 2012; Beer & Boswell, 2001;

Boswell & Dixon, 1993; Pickett & Wilkinson, 2015; Wilkinson, 2011). As we saw earlier, such changes elicit the pressure of having to rapidly adapt to unnatural, market-imposed ideologies, which strips individuals of any ―sense of control or coherence‖ (McCubbin, 2009, p. 304). This sense of coherence is one in which individuals are connected to their natural environments and have a sense of meaning, which is one of the most fundamental precursors for emotional health and resilience (McCubbin, 2009).

Modernity also brings about a pathological obsession with change, overwork, and the overburden of choice, thereby emotionally crippling many ‗modernized‘ individuals (Kirmayer,

2002). Instead of suffering from privation and injustice, the wealthy can suffer from overstimulation, a loss of social connectedness, and/or emotional hypochondriases leading to the phenomenon of the ―worried well‖ (Kirmayer, 2002; Frances, 2013). However, rather than learning from the mistakes of hyper-modernized, or quintessentially ‗American‘ societies, non-

Western countries can sometimes idealize the Western world and subsequently experience a

‗Western‘ transformation. This is particularly true during times of economic flux, as we will see below.

During the 1980s, Japan outdid the United States in technological innovation, dominated the automobile industry, and had one of the highest GNPs per capita among industrialized countries (Inglehart, 1997). In other words, Japan became the global epitome of industrial efficiency and was ranked as one of the richest countries in the world by 1990. Owing to its powerful economy and its initial refusal to accept depression as a pathology (Kitanaka, 2006),

Japan provides a particularly fascinating context to understand how a country that had relatively few antidepressant sales in 2000 became a multi-million dollar hub for Big Pharma in 2001

(Kirmayer, 2002).

Prior to their market crash in the late 1990s, which led to a minimum of 30,000 reported suicides per year, the modern Western concept the ‗self‘ was virtually non-existent in Japan

(Kitanaka, 2006). Although Japanese psychiatry was considered to be the most advanced in East

Asia (Kitanaka, 2006), depression was not linked to suicide by healthcare providers (Kirmayer,

2002). Instead, the Japanese called the condition karô jisatsu, which translates to ―suicide of people who are driven to take their own lives by excessive overwork‖ (Kitanaka, 2006, p. 194).

In some cases, young adults would prematurely die from either heart failure or excessive alcohol consumption owing to a syndrome known as karôshi, meaning ―people who literally work themselves to death‖ (Kitanaka, 2006, p. 194). Japanese health professionals, however, refused to attribute these factors to depression.

In the West, depression has become a cultural idiom describing an unpleasant low mood, lack of motivation and high levels of fatigue, where individuals are encouraged to look inward to resolve their problems and become more functional (Kirmayer, 2002). Since Japanese psychiatry was heavily influenced by German neuropsychiatry, the Japanese do not hesitate to treat anything that is understood as a biological disorder (Kirmayer, 2002; Kitanaka, 2006). The

Japanese culture, however, is grounded in Buddhist beliefs; what is largely construed as a depressive state in North America is actually considered to be a path of enlightenment in

Japanese culture. Therefore, there was no initial market for antidepressants (Kirmayer, 2002;

Kitanaka, 2006). Even if we view this from a critical perspective, this cultural system of interpreting melancholia was merely a method of normalizing suffering caused by an oppressive

work environment in which individuals were encouraged to literally work themselves to death.

This is analogous to religious notions of salvation or redemption through suffering or penance.

However, melancholia – or utsushô – unlike depression, was not internal, pathological, or biological, but was attributed to external factors (Kitanaka, 2006). Individuals were encouraged to look outward to find meaning in their melancholia owing to the Buddhist belief that everything – including pain – is temporary (Kirmayer, 2002; Kitanaka, 2006). Therefore, by looking outward, the onus of distress and healing were not on the individual and any medication that was capable of numbing melancholia was considered to be destructive to an individual‘s morality, resilience, and spiritual development (Kirmayer, 2002).

How bio-marketing can lead to self-transformation. The old adage ‗follow the money‘ needs to be resurrected when attempting to understand how ‗the self‘ is transformed. What a change in self-perception requires is a redefinition of morality, or a generational shift in perceptions of what it means to be human (specifically, a ‗good‘ human) (Applbaum, 2006;

Kirmayer, 2002). This has, historically, and globally, been driven by economic factors (Inglehart,

1997; 2006; Inglehart & Welzel, 2010). For instance, prior to launching a specific drug (or any other products) in a country, market analysts will generally design a ‗SWOT matrix‘ which assesses the strengths, weaknesses, opportunities, and threats of a potential market (Kotlet, 2000, as cited in Applbaum, 2003). This allows marketers to forecast the viability of a potential market.

In 1989, Big Pharma representatives tested the waters in Japan, however Japan declined because they felt that depression did not exist there. In other words, the ‗opportunity‘ to amass large revenues from antidepressant sales in Japan was low. Additionally, the fact that mental illness was severely stigmatized in Japan and that medical ethics in Japan required that psychoactive substances go through additional testing by Japanese health authorities prior to approval posed a

major threat to Big Pharma. This prompted Big Pharma to withdraw their sales pitch, wait for an opportunity to arise, and find ways to mitigate these threats (Applbaum, 2006).

Japanese psychiatry expanded after the adoption of the ICD and DSM when some psychiatrists began reporting depression and high suicide rates in Japan, thereby the set the stage for Big Pharma to make their move. This also demonstrates a key feature of globalization: that the line between intrinsic factors (i.e., the expanding field of psychiatry in Japan) and extrinsic factors (i.e., Big Pharma‘s attempt to profit from anti-depressant sales) become blurred

(Applbaum, 2006; Saul, 2009). Once the opportunity side of the SWOT equation was open, the threats to Big Pharma were mitigated when the vice president of PhRMA operations in Japan convinced the Japanese government to lower the barriers to free trade. This meant allowing free- flowing international trade between Western pharmaceutical companies and pharmaceutical companies and hospitals in Japan by not mandating ‗unnecessary‘ retesting of drugs, because this would be in the best interests of the Japanese people owing to the depression ‗epidemic‘ in Japan

(in Applbaum, 2006, p. 93). In other words, the successful implementation of a free-market in healthcare typically involves bridging the gaps between local and U.S. healthcare practices and promoting what appears to be a democratic healthcare system, since physicians, their patients, and the general public will be ‗free to choose‘ more ‗appropriate‘ treatment plans for their depression and suicidal thoughts (Applbaum, 2006; Kirmayer, 2002; Kitanaka, 2006).

In addition to conducting institutional ethnographies, Applbaum (2006) interviewed psychiatrists, researchers, and marketing specialists who travelled to and from Japan to launch a particular SSRI drug (the details of which Applbaum omitted). These individuals claimed that clinical testing in Japan was ―quite poor‖ and Japan had ―no good clinical practice‖. One said,

―their hankering for precision may pay off for making cars or electronics… but fails them in

medicine‖ (p. 95), and that their clinical research and practice are not ―rationally supervised‖ by internationally recognized and regularized organizations. One of these organizations is the

International Conference for Harmonization of Technical Requirements for Registration of

Pharmaceuticals for Human Use (ICH) who promote ‗Good Clinical Practice‘ globally (although they are headquartered in Geneva, their guidelines are primarily built upon American standards of ethical practice) (Applbaum, 2006; ICH, n.d.). Big Pharma does not only have the support of corporations such as IMSHealth and PhRMA, but also has a supportive working relationship with the WHO: the WHO Nations for Mental Health ―gratefully acknowledges the financial support of Nations of Mental Health by the Eli Lilly and Company Foundation‖ (WHO, 2002, p.

2). As one manager of PhRMA said to Applbaum (2006), ―it takes a whole industry to make a market… It‘s going to take all of us‖ (p. 92).

PhRMA‘s first move was to help Big Pharma seek approval from local health authorities in

Japan, such as the Ministry of Health, Labor and Welfare (MHLW, or koseirodosho). According to Applbaum‘s (2006) interviews with executives who negotiated with the MHLW, Big Pharma felt that the randomized clinical trials (RCTs) in Japan were too stringent. They claimed that the

Japanese healthcare industry practiced ‗junk science‘, and that their treatment of their mental health population is ‗inferior‘ relative to Western practices. Therefore, they began making moral and ethical assertions and claimed that they wanted to help Japanese sufferers. Because it‘s costly to conduct clinical trials in Japan and the Japanese are generally more sceptical of psychopharmacology, they were frustrated that the Japanese medical authorities called for retesting. However, by accusing Japanese medical authorities of political cronyism (i.e., local clinicians whose associates in MHLW recommend and help market a local as opposed to a foreign drug), PhRMA was able to warn the public that the local Japanese population was

suffering owing to a weak mental healthcare system. No government – especially the health industry – wants to be publically accused of harming its population. Therefore, Japan sought to implement some damage control by working with the U.S. to develop the ‗US-Japan Framework for a New Economic Partnership‘ (Applbaum, 2006). This involved a policy initiative called the

‗U.S. – Japan Enhanced Initiative for Deregulation and Competition‘ (Ministry of Foreign

Affairs, Japan, 1997), in which one of their basic principles was to:

Address reform of relevant government laws, regulations, and guidance which

have the effect of substantially impeding market access for competitive goods and

services in order to enhance consumers‘ interests and to increase efficiency and

promote economic activity (Principle B, para 2).

The policy further states that by removing ―sectoral and structural impediments to expand international trade and investment flows‖ (Principle C, para 3), there are less restrictions in commerce between Japan and the U.S. This meant that the requirement of the last phase of RCTs that were originally carried out in Japan was officially abolished, and Japanese health practitioners could accept ‗bridging studies‘ (i.e., data on Japanese patients in foreign countries)

(Applbaum, 2006). Now that the U.S. – Japan connection in commerce was official, PhRMA began advocating for mental healthcare using social marketing practices such as advertising, branding, and promotional campaigns (Applbaum, 2006). These awareness campaigns occurred in conjunction with local Japanese psychologists who were supported by PhRMA and WHO‘s

Nations for Mental Health Program. Ultimately, concerned mental health practitioners and public agencies, reporters and journalists began promoting Western concepts of mental illness.

The promotion of a Western mental health model began by making public moral assertions to ‗educate‘ patients to take mental health care into their own hands and make ‗rational‘

decisions about their wellbeing. In other words, if they were not taking care of their loved ones by recommending mental health services to them (or seeking services for themselves), they were not being good moral citizens. By promoting ‗mental health awareness‘ campaigns, PhRMA was able to manipulate consumer consciousness and elicit a free-market economy in mental health care. This means that as ‗knowledge‘ about depression infiltrated the media, it was only a matter of time before Japanese patients demanded to be treated like those in more ‗advanced‘ Western countries like America. And then it became a waiting game; as PhRMA encouraged mental health advocacy groups, the Japanese government was challenged to provide better treatment for its population, after which Big Pharma delivered their sales pitch, and finally succeeded. From having virtually no market for antidepressants in 2000, the sales for fluvoxamine (Faverin,

Luvox) and paroxetine (Paxil) alone amassed 2.6 billion yen (approximately $25 million US) per month in 2001 (Applbaum, 2006; Kirmayer, 2002). And there it was, slapped onto the face of

Japanese healthcare: neo-liberalism masked as morality and democracy at its finest.

The Big Pharma-Psychiatry complex significantly transformed Japan on a societal level by changing the cultural discourse of depression (Kitanaka, 2006). The traditional Japanese (and broadly, the Asian) sense of self is multifaceted in that there is no dramatic ‗private inner theatre‘ in which an individual narrates their lived experiences as the protagonist of their lives (Kirmayer,

2002; Kitanaka, 2006). Instead, their sense of self and agency is closely tied to Mead‘s (1925) notion of consciousness whereby an individual‘s identity is relatively fluid and ephemeral, located in the ―space between individuals where a web of obligations, respect and mutual nurturance can be developed‖ (Kirmayer, 2002, p. 308). It is the ‗other‘ aspects of this definition

– the obligations, respect and mutual nurturance – that form the most pivotal aspect of their identity, which echoes the continental philosophical view of the self as a constellation of social

relationships (Russon, 2010). These cultural definitions of self began to shift around the same time that antidepressants were mass-marketed in Japan.

From having social meaning, melancholia became pathological and entered the everyday

Japanese lexicon. Japan (in some ways, rightfully so) was criticized for being a culture of overwork, where individuals were unable to keep up and experienced burn-out. Japanese society was transformed in at least three ways: first, from being a path to resilience, melancholia became a pathology where individuals became ―objects of biological management‖ (Kitanaka, 2006, p.

13). In other words, individuals began looking inward rather than outward to understand emotional pain. Second, SSRIs replaced depression as an agent for well-being. Third – and most importantly – the modernization of psychiatry in Japan acted as a barrier to protesting against harsh work environments. What it did, instead, was cause individuals to protest against their own psyches. For instance, some psychiatric patients who Kitanaka (2006) interviewed felt that their depression became a ―work hazard‖ (p. 169). By marketing SSRIs using common language – i.e., promoted the notion of ―kokoro no kaze‖ (―the soul catching a cold‖, p. 15) – there was no reason to question authoritative forces when individuals could question their minds.

Illness negotiation as a social and political process. The previous sections demonstrated that the prevalence of mental disorders increased transnationally after they were codified and entered public consciousness, typically during times of economic crisis after natural disasters or market crashes (there will be a separate section on the impact of war when discussing Kuwait in

Chapter 5). They also established that the use of psychopharmacology begins (or increases) as an offshoot of the increased reporting of ‗mental disorders‘ which generally occurs when physicians rely too heavily on the ICD or DSM (we saw in the previous chapter that this is not the case with the French, who have their own classification system for some disorders). Although the role of

Big Pharma in shaping public consciousness was discussed, the specific social processes that drive phenomenological changes in mental disorders have been unclear. This unlocks a controversial debate of whether a disorder increases in prevalence because it was previously overlooked and therefore underreported; or, whether professional writing is capable eliciting actual phenomenological changes of an illness (i.e., how the illness is experienced) thereby shaping a patient‘s explanatory model of an illness (Katzman & Lee, 1996; Swartz, 1987;

Watters, 2010).

One way we can understand phenomenological change is by exploring the notion of illness negotiation. Illness negotiation was first described by scholars who adopted a critical feminist approach to analyzing eating disorders (e.g., Katzman & Lee, 1996; Swartz, 1987), however it is used here to highlight the specific processes that shape the subjective manifestations of mental disorders in general. Illness negotiation in mental health care, first described by Swartz (1987), is based on the medical anthropological view that pathology is a clinical transaction between doctor and patient as a method of understanding a patient‘s suffering. This process is affected by both the patient‘s subjective experience of an ‗illness‘, which can be shaped by media, family, and religion as well as a clinician‘s technical understanding of a ‗disease‘ (Swartz, 1987).

Medical anthropologists and sociologists have been arguing for more than four decades that mental disorders are both culture and value specific. They also state that clinicians tend to focus on Euro-American explanatory models of disease which in turn influences how they treat their patients as well as what is presented to the media (Kleinman, Eisenberg, & Good, 1978;

Kleinman & van der Geest, 2009; Shorter, 1997; Watters, 2010). However, the fact that the very

backbone of healthcare practices is predicated on psychological ‗science‘ – the outcomes of which many believe is value-free, objective, and resistant to economic, political, and cultural forces – is generally taken for granted by many clinicians (Castillo, 2006; Lee, 1995). As we saw earlier in the chapter, mental illness (or what is perceived as such) can vary in prevalence and severity both historically and transculturally.

A successful therapeutic alliance occurs when a patient and clinician build rapport and establish common ground during therapy (Norcross & Wampold, 2011; Swartz, 1987).

Professionals agree that ‗care‘ and ‗empathy‘ as well as an understanding of the importance of culture, religion, and socialization are crucial in building a successful therapeutic alliance during psychotherapy (Kleinman & van der Geest, 2009; Norcross & Wampold, 2011; Swartz, 1987).

They also stress the importance of adapting therapeutic modalities to patient characteristics

(Norcross & Wampold, 2011). Some have argued that the psychotherapy alliance, however, can sometimes be just as much of a naïve and reductive position as the psychiatric one. Despite the effort, it is impossible for a therapist to be a blank slate and set aside their beliefs since the language of professional training become intertwined with the clinician‘s set of assumptions, socioeconomic class, and socialization (Orange, 2001; Swartz, 1987).

Sociologists in particular contend that illness beliefs are not innate, but socially constructed, and the meaning and experience of health and illness are derived from social meaning systems; these in turn shape how we present ourselves as moral individuals (Hodgetts &

Chamberlain, 2000; Radley & Billig, 1996; Swartz, 1987). Both patient and clinician will bring their own preconceived notions with them and any agreement or consensus that is reached in therapy is layered on top of these beliefs. Cooley‘s (1902) notion of the looking glass self is particularly relevant here; since both the clinician and patient are capable of acting as mirrors for

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each other, the therapeutic process resembles more of a social process rather than a ‗clinical‘ one. This means that if any common ground is established, it is largely socially constructed.

Therefore, the argument made here is that 1) clinical encounters affect both the patient‘s and the clinician‘s explanatory models of illness and disease (although the power generally resides with the clinician, making it an unsymmetrical negotiation); 2) the knowledge gained through these encounters shape popular beliefs in the media (e.g., through case studies and other research); and

3) these popular beliefs can shape cultural understandings of an illness and, in turn, affect a patient‘s explanatory models of illness.

The term ‗mental health literacy‘ was introduced by Jorm et al. (1997, in Jorm, 2000) to assess the layperson‘s ―knowledge and beliefs about mental disorders which aid their recognition, management, or prevention‖ (p. 396). Jorm criticizes the general public for not being able to ―correctly recognize‖ and ―understand the meanings of psychiatric terms‖ (p. 396).

He came to this conclusion based on his research in Australia that assessed the general public‘s ability to correctly diagnose schizophrenia and major depression based on vignettes that were presented to them. Jorm‘s (2000) argument gets even better; he points out that a lack of mental health literacy is a ―failure‖ on the patient‘s part as it can result in poor communication with clinicians and can result in misdiagnoses by general practitioners: ―detection of a mental disorder is greater if the patient presents his or her symptoms as reflecting a psychological problem‖ (p.

397). In other words, Jorm effectively feels that it is the patients‘ responsibility to internalize medical/psychiatric discourse, self-diagnose themselves, and accurately play out the symptoms that physicians need to explicitly observe in order to make a correct diagnosis; in the event that there is a misdiagnosis, the patient is to blame because they are not ―literate‖ enough in psychiatric nosology.

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One of Jorm‘s (2012) recent articles in the American Psychologist further reinforces the importance of mental health literacy as a route to ‗empowerment‘, but this time he recommends increasing mental health literacy in developing countries through mental health campaigns

(which can be, as we have seen, bio-marketing campaigns), owing to ―major discrepancies between public and professional views‖ (p. 233). Regardless of what some mental health professionals say about culture, religion, and the importance of being client-centered (e.g.,

Norcross & Wampold, 2011), Jorm‘s ideology is (as demonstrated earlier with examples from

China, Sri Lanka and Japan) far more reflective of what can actually happen when mental healthcare lands in countries outside the Western world: Western-trained mental health professionals can often impose their own beliefs onto a population and undermine indigenous methods of understanding and coping with distress. Ultimately this is attributed to a country not having an ‗enlightened healthcare policy‘ (Applbaum, 2006). It is no surprise that mental healthcare receives so much criticism and resistance as its entire foundation is built on values that self-aggrandize the discipline and shame anyone who does not reinforce its authority. Based on these findings, only those who adopt a mainstream North American psychiatric view of mental health and illness are considered to be literate, civilized, empowered, and enlightened.

Mental health literacy bleeds into illness negotiations in that the clinician will generally play the role of a ‗translator‘ or advocate of their professional model and act as an interpreter of the patient‘s experience, focussing more on symptoms that reinforce their professional beliefs

(Swartz, 1987). Owing to the unequal power differential between doctors and patients, patients will generally see themselves the way their clinician does; to this end, as clinicians‘ perceptions of what an illness is changes over time, so will a population‘s experience of that illness (e.g., the rise and fall of hysteria and anorexia, in Shorter, 1986; 1987; Lee, 1995). As we saw with self-

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starvation in China, people will naturally try to make sense of their symptoms and will adopt any explanations that are available to them, especially as adolescents and young adults. These symptoms are then discussed in scientific journals and social media outlets, resulting in a positive feedback loop since increased numbers of individuals who begin manifesting symptoms further validates the disease as it becomes culturally accepted. Therefore, illness negotiation is not merely a social or clinical process, but a political one that is globally homogenizing the meaning of self, health and healing.

A „Global Mental Health Epidemic‟

There are several mental health care and crisis intervention models written by international mental health ―experts‖ from the Red Cross International (RCI), World Health Organization

(WHO), the Global Development Group (GDG), National Center for Post-traumatic Stress

Disorder (NCPTSD), the National Center for Traumatic Stress (NCTSN), and the European

Society for Traumatic Event Studies (ESTES), all of which rely heavily on the DSM and ICD

(Afana, 2012; Summerfield, 2008; von Peter, 2008). Some mental health clinicians and researchers are highly supportive of these global humanitarian efforts and recommend democratic and culturally appropriate methods of rebuilding communities and resilience after a disaster (e.g., Murray, Davidson, & Schweitzer, 2010), while others more blatantly critique these modules for being individualistic, mechanical, and for promoting a rather pitiful portrayal of humanity on a global scale (Afana, 2012; Summerfield, 2006; 2008; von Peter, 2008; Watters,

2010). For instance, the Global Development Group (GDG) predicted that the 2004 post-tsunami survivors would be fraught with feelings of ―anger, guilt, helplessness and sadness‖ (von Peter,

2008, p. 643); the NCPTSD warned professionals to look out for ―irritability, sadness, and

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anger‖ and even claimed that the prevalence of mental illness can reach upwards of 81% of the affected regions (Norris, 2005, in von Peter, 2008, p. 643).

The discourse that is common among all these modules is that natural responses to traumatic events are pathological and that trauma is most severe when coping capacity is less than what is required to overcome stress (von Peter, 2008). The issue here is that they are projecting a very individualized method of coping onto non-Western populations, where, as we saw in earlier sections, coping can look quite different. The World Health Organization (WHO) also recently published a Mental Health Action Plan for 2013-2020 which recognizes the political and economic factors that contribute to mental health issues (WHO, 2013a). The entire

50-page document, however, is more theatrical than it is educational. Statements such as ―a concomitant need for more mental health and social services‖ to help ―the emergence of new vulnerable groups‖ (p. 7, emphasis added) is definitely enough to trigger a tidal wave of state-of- the-art mental health care across the globe for the following populations:

Members of households living in poverty, people with chronic health conditions,

infants and children exposed to maltreatment and neglect, adolescents first exposed

to substance use, minority groups, indigenous populations, older people, people

experiencing discrimination and human rights violations, lesbian, gay, bisexual, and

transgender persons, prisoners, and people exposed to conflict, natural disasters or

other humanitarian emergencies (WHO, 2013, p. 7)

However, these populations are not always ―new‖ or ―vulnerable‖. In fact, even some of our closest primate relatives will engage in Machiavellian politics to maintain their status quo (de

Waal, 2007). The WHO (2013a) acknowledges the negative emotional impacts of some socioeconomic factors (such as poverty), and rightfully recognises that mental health issues can

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be more prominent in countries that experience economic and political strife. However, developing resistance in the face of challenge is not foreign to our species. For instance, individuals living in the Middle East and North Africa (MENA) regions and South Asia – who are frequently exposed to war or natural disasters – have actually shown to develop high resilience in the face of life-threatening adversity (Afana, 2012; Ganesan, 2006; Watters, 2010).

Additionally, none of these issues are individual mental health issues per se, but sociopolitical ones that contemporary mental healthcare may be, despite its association with philanthropy, too misguided and ill-equipped to tackle. Addressing these as ‗mental health issues‘ is pathologizing, infantilizing and acts as more of a band-aid on a gunshot wound where in some cases, the mental health and pharmaceutical industries themselves are the perpetrators (i.e., by over-reporting or exaggerating the severity of mental illness in foreign countries to validate their profession, as we saw earlier). For instance, Summerfield‘s (2006) analysis of disaster efforts reveals that millions of children who die from poverty in third world countries are not as much of an emergency, but seen as ‗normal‘. However, when a country is exposed to a natural disaster or a war, psychological aid will go rushing in like the A-Team, transforming societies into research sites for various therapeutic modalities, highlighting how little many mental health advocates are genuinely concerned with philanthropy unless they can get published, make the tabloids, or reinforce their identities as global saviours and martyrs.

Even though The WHO (2013a) clusters human rights violations with mental health issues, its goal to promote human rights is, nonetheless, noble. In fact, claiming to do anything ‗in the name of human rights‘ will immediately win almost anyone recognition from global agencies.

For instance, Dr Margaret Chan, the current chairman of the WHO outlined the four goals of the

WHO‘s (2013a) Mental Health Action plan as: 1) effective mental health legislature in all

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member states; 2) community-based (i.e. public, non-for-profit) care; 3) mental health promotion and mental illness prevention; all grounded in 4) evidence-based research. The fundamental issue with these goals is that they conflict with each other (see below), thereby rendering them futile to systemically tackle human rights issues.

Much of the ―evidence-based research‖, as we have seen in the former sections, is funded by private corporations (or worse – tax-payers money), is highly skewed, generally lacks cross- cultural validity (in fact, any validity), can be non-empirical (i.e., assuming, based purely on

―logic‖ rather than observation, that reactions to trauma are consistent world-wide), and is geared more towards benefiting private corporations rather than communities (e.g., Greenberg, 2013;

Applbaum, 2006). Additionally, mental health research that counts as evidence-based research is largely conducted by psychologists and psychiatrists who are either blind to – or in some cases, will blatantly ignore – empirical research that falls under the domain of medical anthropology, sociology, and critical theory. These disciplines have revealed that mental health advocacy programs (i.e., awareness and anti-stigma campaigns) are primarily bio-marketing campaigns that negatively impact individuals and sharply contradict ethical discourses. Additionally, the definition of ‗effective mental health legislature‘ is commercially and ideologically driven, as it calls for the deregulation of policies that inhibit the mass-marketing of pharmaceuticals as we saw in Japan. The call for community-based and not-for-profit care is a promising goal; however, what might be considered not-for-profit care in countries that publically fund psychopharmacotherapy (e.g., Kuwait, as we will see later), is actually profitable for Euro-

American pharmaceutical companies.

Although the WHO (2013a) acknowledges the interplay between culture and mental health, it is essentially homogenizing the meaning of wellness across societies by indirectly

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advocating for the DSM by harmonizing it with the ICD (see DSM-5, APA, 2013). A primarily goal of the marriage between the DSM-5 and ICD-11 (which is being published in 2018) is to consider the ―global applicability‖ of mental health research results and ―replicate results across national boundaries‖ (APA, 2013, p. 11). Additionally, despite the fact that the efficacy of SSRIs have been discredited (see Healy, 2006), the WHO still lists Prozac (as fluoxetine) and lithium carbonate in their list of most essential medications for every country (see WHO, 2013b, p. 31-

32). This is not surprising, considering that Eli Lilly has been sponsoring the WHO‘s global mental health efforts for at least over a decade (WHO, 2002). Finally, given the WHO‘s propensity to rely on and promote what is often thought of as evidence-based research, there is little room to challenge the systemic issues that promote inequality and human rights violations.

By recommending the treatment of mental disorders with contemporary mental health care, the

WHO is essentially supporting the notion that mental disorders are individual issues, rather than socioeconomic and political ones. To quote Arthur Kleinman:

Most of the disasters in the world happen outside of the West. Yet we come in and

we pathologize their reactions. We say, ―you don‘t know how to live with this

situation.‖ We take their cultural narratives away from them and impose ours. It‘s a

terrible example of dehumanizing people. (Kleinman, in Watters, 2010, p. 107).

Despite the torrent of research that criticizes the problematic aspects of modern mental healthcare, there is very little recommendation on where to go from here. Some have recommended a redefinition of ethics and morality by resurrecting continental philosophical notions of ‗care‘ (such as those proposed by Heidegger) and assessing them in light of current clinical practices (Kleinman & van der Geest, 2009). More recently – after Watter‘s (2010)

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critique of cross-cultural mental health practice, Greenberg‘s (2013) verbal annihilation of all the

DSM manuals, and Frances‘ (2013) ―insider‘s revolt‖ and exposé of the APA and Big Pharma‘s fraudulent practices – others have recently suggested resurrecting the notion of dialectics to assess the tensions between different ideologies regarding ‗care‘ (i.e., social justice versus value neutrality) in an effort to reconceptualise the ethics regarding caregiving practices (e.g., Harrist

& Richardson, 2012; 2014). Both of these recommendations fall under the domain of critical and social justice oriented mental health theory, research, and practice (Chapter V). The next chapter

(Chapter IV) is devoted to understanding the history, culture, and mental health sector of Kuwait, as we know it today.

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Chapter IV. History, Culture, and Mental Healthcare in Kuwait

Kuwait is a very small Middle Eastern country situated along the Arabian Peninsula bordered by

Saudi Arabia, Iraq and Iran, which are significantly larger. It is one of six Gulf Cooperation

Council (GCC) countries along with Bahrain, Oman, Qatar, Saudi Arabia, and the United Arab

Emirates (Fasano & Iqbal, 2003). Kuwait has a long history of colonialism, economic expansion, and cultural development since it is a major maritime trading hub between East Africa and South

Asia and also resides on a bedrock of oil wealth (Klaum, 1980; Pfeifer, 2002). Kuwait was a

Portuguese colony in the 16th century, established itself as a trading route in the 17th century, and officially became a city-state in the early 18th century after the Al-Sabah family settled and established themselves as a political community along the bay of Kuwait (Klaum, 1980; Pfeifer,

2002). Since then, the Al-Sabahs have been the primary rulers, or sheikhs (f. sheikhas) of Kuwait

(Richards & Waterbury, 1998). The Al-Sabahs also established Kuwait as a British Protectorate from the late 19th to mid-20th centuries to circumvent European and Ottoman colonialism. After gaining considerable oil wealth in the 1950s, Kuwait gained independence from British rule in

1961 and became the largest producer and exporter of oil in the Middle East during that time, accumulating hundreds of millions of dollars annually (Pfeifer, 2002). Similarly, Kuwait sought aid from the U.S. during the 1990 Iraqi occupation of Kuwait and both countries have since become strong allies. Given Kuwait‘s large oil reserves, small size, and it its geographical location amidst larger countries experiencing major political strife, Kuwait is an easy target for violence and colonialism and is thus at the constant mercy of foreign military aid.

Despite being a very small country – occupying just less than 18,000 square kilometers, which approximates the size of New Jersey – Kuwait owns more than 6% of the world‘s crude oil reserves, thereby having the 6th largest reserves in the world (Organization of the Petroleum

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Exporting Countries [OPEC], 2016), and plans to escalate production to 4 million barrels per day within the next 5 years (The CIA World Factbook, 2015). Even with increased production,

Kuwait has more than 200 years remaining of estimated oil production, which exceeds that of

Saudi Arabia (100 years) and Iran (75 years; extrapolated from Richards & Waterbury, 1998, p.

54). With a GDP per capita of approximately US$ 72,000 and gross national saving of 55% of their total GDP (US$ 180 billion), Kuwait currently ranks 5th and 3rd among the world‘s wealthiest countries, respectively (The CIA World Factbook, 2016).

Since its discovery of oil, Kuwait has grown very rapidly and is also becoming more modernized (specifically, Westernized) with every decade (Barrett & Behbehani, 2003).

Although Arabic is the native language of Kuwait, English is very widely spoken, and Kuwait also has one of the highest literacy rates (96%) in the Middle East (Alhaj, 2015; WHO, 2014).

Kuwait is predominantly Muslim (65% Sunni, 35% Shi‘a) and currently has a population of approximately 4 million, out of which only 31% are Kuwaiti nationals while the remaining are

Asian (38%), other Arabs (28%), African (2%), and other (1%), which include those of

European, North and South American and Australian origin (The CIA World Factbook, 2016).

(The Kuwaiti government has not posted recent population demographics online however the ones listed in U.S. sources are likely very accurate owing to the strong alliance between Kuwait and the U.S.). It is important to note that these figures do not include U.S. military personnel

(approximately 20,000) who cycle in and out of Kuwait or individuals illegally living as residents on visitor visas such as North American and European teachers therefore the numbers of Westerners are much higher in Kuwait than what is reported (―Illegal Teachers run from

Beladiya in Kuwait‖, 2015; Mark, 2015; The CIA World Factbook, 2016). The Bidoon (meaning

‗without‘, i.e., ‗without nationality‘ or stateless immigrant) population of Kuwait is

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approximately 150,000; they are largely believed to be Iraqi, Palestinian, and other nomads from neighbouring countries who settled in Kuwait before and during the 1990 Iraqi occupation and destroyed their legal documents to claim Kuwaiti citizenship (Richards & Wataerbury, 1998;

Tétreault & al-Mughni, 1995). Owing to their inability to provide legal documentation to prove that they were Kuwaiti by birth, the Kuwait government denied Bidoons Kuwaiti citizenship, but provided them with the same subsidized public healthcare rights as other non-citizen residents of

Kuwait (Shah, 2007; Wills, 2013).

Given their surplus of oil wealth and the fact that Kuwaitis are a minority in their own country, Kuwaiti nationals generally enjoy a very high material standard of living comparable to high income populations in developed countries (El-Katiri, Fattouh, & Segal, 2011; Richards &

Waterbury, 1998). The Kuwaiti government fully subsidizes all utilities and public healthcare for all nationals and foreigners living as residents in Kuwait; food, housing and education (including post-secondary education in the areas of business, medicine, and engineering) are also subsidized for Kuwaiti nationals, who are given an additional monthly social allowance (which increases with every child born into a family). Given the added benefit of high and tax-free salaries to

Kuwaitis and all foreigners in non-manual or domestic labour positions in Kuwait, the region attracts professionals from all over the world who want to enjoy financial prosperity (El-Katiri et al., 2011).

Kuwaitis are predominantly employed in the governmental sector, while migrants make up most of the workforce in the private sector (El-Katiri et al., 2011). Additionally, since Kuwait is still experiencing rapid urban development, Kuwait‘s economy is highly dependent on migrant physical and domestic labourers (Richards & Waterbury, 1998; The CIA World Factbook, 2014).

Given these economic nuances, migrant workers serve to both promote economic growth and

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afford socioeconomic and ethnic class formation in Kuwait. Locals can and generally do avoid physical labour jobs that are hard, dirty or dangerous and these jobs tend to be taken by migrant workers (Shah, Shah, Chowdhury, & Menon, 2002). Only in the Arabian Gulf states – particularly Kuwait – do low-wage migrant physical workers outnumber the locals (McKenzie,

Theoharides, & Yang, 2014; Richards & Waterbury, 1998). During the last decade, Kuwait has become notorious for endorsing major human rights violations – primarily targeted towards

Asian (primarily Indian and Filipino), other Arab (e.g., Egyptian) and African foreign workers.

These violations include forced labour, torture, arbitrary arrest or imprisonment, human sex trafficking, sexual abuse, and denials of fair public trials – all of which are prohibited by the constitution and the law in Kuwait (United States Department of State, 2013). Interestingly,

Kuwait did not always have a history of treating its population poorly; in fact, during the middle part of the 20th century, Kuwait was considered to be the most progressive and egalitarian of all

Middle Eastern countries in what was described as the ‗Golden Era‘ of Kuwait (Al-Nakib, 2014;

Al Sager, 2014; Kluijuer, 2013). This period, however, was very short-lived.

Kuwait‟s Golden Era and Islamic Resistance

Between the 1940s and the 1980s, Kuwait increased oil production and rapidly became the most developed country in the Middle East (Al-Nakib, 2014; Al Sager, 2014; Kluijuer, 2013). Kuwait began to excel in education, art, literature, and theatre, and was the most liberal country in the

Arab world in terms of freedom of expression and flew head first into the Arab renaissance.

Women also wore what they wanted to wear; it was rare for women to wear a hijab, and more common for them to wear miniskirts at university (which is almost unheard of today). Kuwait began echoing the feminist and social movements that were taking place in the West as education, urbanization, and economic development began opening doors for women to enter the

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workforce and take part in political discussions. Such venues for women‘s further enfranchisement included the International Feminist Networks, the UN‘s International Women‘s

Year (1975), and the Decade for Women (1975-85) which facilitated world-wide women‘s movements, including The Women‘s Cultural and Social Society of Kuwait, which is the oldest women‘s organization and participant of the Pan-Arab and UN conferences since the 1970s

(Gunter & Dickinson, 2013; Kinninmont, 2013; Meuleman, 2002; Sager et al., 2008).

Al-Mughni‘s (2010) analysis of Islamist women‘s narratives on female oppression reveals the frustration that women began voicing towards male-dominated Islamist groups, to the extent that they strongly influenced Arab nationalism. Political life during Kuwait‘s Golden Era became highly secular as nationalists and leftist groups dominated parliament and advocated for political, economic, and social reform and were making headway towards a relatively egalitarian society. This societal shift also changed the roles for women on the home front as the traditional family way of life, based on tā’a (‗obedience to the patriarchal head‘) began to wane

(Meuleman, 2002) and Arab feminists, such as Nawal Sa‘dawi, began publicly voicing the perceptions that many Arab Muslim women held towards men in the private domain:

Arab men, and for that matter most men, cannot stand an experienced and

intelligent woman…he knows very well that his masculinity is not real, not an

essential truth, but only an external shell, built up and imposed on women by

societies based on class and sexual discrimination. The experience and

intelligence of women are a menace to this patriarchal class structure, and in turn,

a menace to the false position in which a man is placed, the position of king or

demi-God in his relations with women. This is essentially why most men fear and

even hate intelligent and experienced women. Arab men shy away from marrying

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them, since they are capable of exposing the exploitation inherent in the

institution of marriage as practised to this day. An Arab man, when he decides to

marry, will almost invariably choose a young virgin girl with no experience,

imbued with a childish simplicity, naïve, ignorant, a blind ―pussy cat‖ who does

not have an inkling of her rights. (in Karmi, 1996, p. 165)

Resistance to public feminist discourse and social movements, however, was inevitable as they triggered strong religious responses during the 1980s after which more conservative

Islamic representatives began winning a foothold in parliament (Al-Mekaimi, 2013; Meuleman,

2002). To protect traditional values and to weaken the secularism by gaining full access to the public space, Islamist groups went to the extent of blaming ―child delinquency and divorce on women‘s participation in the labour force‖ (Al-Mughni, 2010, para 36) and fought for the official

Islamization of Kuwaiti society in the 1980s as the ‗beginning of a new order‘ (Al-Mughni,

2010, para 3). The ironically named ―Social Reform Association‖, for example, felt that women failed in their duties as homemakers (Meuleman, 2002). In other words, feminism threatened traditional cultural norms so the association responded by campaigning for Sharia (religious

Islamic) law to be the main source of legislation, and even extended the definition of adultery to touching, talking to, or even being alone with an unrelated man (Meuleman, 2002). The association also felt that men and women should be segregated and women should be veiled, and fought for the illegalization of alcohol consumption as well as manufacture, and importation.

Resistance to social reform was also exacerbated during Kuwait‘s support of Iraq during the

Iraq-Iran war and the assassination of Kuwait‘s emir, Jaber al Sabah in 1985; the bombings that took place in Kuwait further stalled social movements as Kuwait gradually became more and

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more conservative (Khadduri & Ghareeb, 1997; Meuleman, 2002). Kuwait‘s social movements, however, took their real and final hit after the 1990 Iraq invasion.

A Brief History of Violence

The most significant event in Kuwait‘s history in the last century was when Saddam

Hussein‘s army launched a massive military attack on Kuwait on the morning of August 2nd,

1990. This came as a big surprise to both Kuwait and the outside world since Kuwait and Iraq became strong allies against Iran just two years prior and Kuwait both financially and politically supported Iraq during Iran‘s raids (Khadduri & Ghareeb, 1997). During this time, Iraq accumulated approximately US $80 billion in debt – mostly from Kuwait and Saudi Arabia – with no intention of repaying it (Richards & Waterbury, 1998). Kuwait‘s refusal to establish itself as an Iraqi province and denial of Iraq‘s request to pardon the debt were the two major triggers of Hussein‘s invasion of Kuwait (Khadduri & Ghareeb, 1997; Richards & Waterbury,

1998). Given Iraq‘s seasoned militia and exceptionally high military intelligence combined with the fact that Kuwait did not foresee the attack, Kuwait was unable to defend itself and it was quickly overrun by a large force of well-armed Iraqi invaders for seven months before the U.S. military drove them out.

During these months, electricity was completely shut off in residential areas and many

Kuwaitis and foreigners fled Kuwait (foreigners were primarily evacuated by their embassies), while many of those who remained were kept as hostages (Greenwood, 1992). Kuwaitis who decided to stay in Kuwait – owing to feelings of loyalty towards their country – endured numerous horrific experiences, including kidnapping, detention, rape, and torture (Nader &

Fairbanks, 1994; Nader, Pynoos, Fairbanks, Al-Ajeel, & Al-Asfour, 1993). As one prisoner said,

―the jailers, in an attempt to frighten us, occasionally showed us some prisoners who had been

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tortured‖ (in Al-Hammadi, 1995, p. 41). It was very common for Iraqi soldiers to shoot young

Kuwaiti men in front of their families. There were even reports of men, women and children being raped and children being hung for singing the Kuwaiti national anthem (Al-Hammadi,

1995; Al-Hammadi & Al-Abdalrazaq, 1994). Reports generally classified these acts as genocide since they were an attempt to cause ―partial or total annihilation of a national, ethnic, racial, or religious group‖ (Al-Hammadi, 1995, p. 33). Most arrests were carried out on public streets, check points, mosques, and people‘s homes after which prisoners were taken to schools, sports clubs, police stations, houses and corporate buildings which were transformed into prisons and detention centres. Additionally, most of the public and private property in Kuwait was looted, and ―not even animals or the environment were spared‖ (Al-Hammadi, 1995, p. 33).

A Kuwaiti psychiatrist, Dr. Abdullah Al-Hammadi (1995), wrote an in-depth account of the war crimes committed in Kuwait, in which the Iraqis were portrayed as ―illiterate, hard- hearted, brutal and inhuman‖ invaders (p. 60), ―devoid of any sense of human decency‖ (p. 47), and who turned the lives of Kuwaitis – portrayed as ―peaceful people‖ (p. 33) – into a ―living hell‖ (p. 35). Most prisoners in Kuwait underwent multiple methods of torture, including beating, sexual assault (e.g., forced intercourse and object rape), suffocation, electrocution, hanging, cutting, dental brutalization and burning; although men were the most afflicted, women and children also endured several different methods of torture, especially sexual, beating, and electrical (for a more detailed report as well as an inventory of photographs of torture victims and torture instruments, refer to Al-Hammadi, 1995, pp. 43-58). Additionally, hundreds of

Kuwaitis (mostly military personnel and those involved in the resistance movement) were taken to Iraq and prisoned for months. As a medical doctor, Al-Hammadi was assigned to treat early batches of prisoners who came back to Kuwait from these prisons and wrote that all the prisoners

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were wearing the same clothes they were arrested in. Many had cholera, typhoid, or hepatitis since they were ―obligated to drink water from the same bowl in which they had urinated‖ (p. 45) and many presented with cigarette burns and gouged eyes. Some of the prisoners were sent back dead and ―had been shot in the back of the head at close range‖. According to his medical reports and the accounts of survivors‘ and family members, ―the Iraqis would bring detainees and ask them to identify them as their sons. After having confirmed their identity, the Iraqis would shoot their victim in the back of the head before his family‘s eyes‖ (Al-Hammadi, 1995, p. 48).

Subsequently, there were several reports of Kuwaiti survivors of the invasion suffering numerous mental health issues, including depression, anxiety, and sleep disturbances (e.g., recurring nightmares) – all of which have had long-term consequences in Kuwait (Al-Hammadi

& Al-Abdalrazaq; Nader & Fairbanks, 1994; Nader et al., 1993; Ismael & Ismael, 2013). In addition to mental health issues, there was a huge environmental aftermath of the invasion in

Kuwait; since Iraqi forces set almost 700 oil wells on fire, much of the country was covered in black smoke and ash for several months (Al-Hammadi, 1995; Khordagui, & Al-Ajmi, 1993).

This also resulted in many long term medical issues in Kuwait, such as congenital heart disease and asthma (Abushaban, Al-Hay, Uthaman, Salama, & Selvan, 2004; Wright et al., 2010).

One of the most significant changes that took place in Kuwait is that Kuwaiti culture, as it presents itself today, is far more conservative than it was before the war. Even though the

Kuwait resistance movement put pressure on the Kuwait government to democratize Kuwait after its liberation, the government had become less tolerant of free public expression as the whole country was in a heightened state of arousal (Greenwood, 1992). The Iraq-Iran war, Iraq‘s betrayal of Kuwait, and the environmental, political, sociological and psychological aftermath of the invasion created a climate that was inimical to democracy. This gradually made Kuwait more

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conservative and authoritarian. Unfortunately, there is a lack of literature that fully explains this cultural shift. The first step in understanding this transition, however, is to examine how religion has come to dictate the legal system in Kuwait.

The Intersection between Religion and Law in Kuwait

Kuwait is currently governed by a constitutional monarchy in which the National Assembly parliament (consisting of 50 members of parliament [MPs]) and the emir, or sheikh (currently

Sabah Al-Ahmad Al-Jaber Al-Sabah), form the legislative and executive branches of governance, respectively (El-Kebbi, 2013; The CIA World Factbook, 2014). Although Kuwait‘s legal system incorporates English common law and French civil law, Sharia law is the main source of legislation in Kuwait (Lombardi, 2013; ―The Constitution of the State of Kuwait‖,

2014). Sharia is considered to be ‗the path‘ in Islam as it offers direction for all aspects of

Muslim life including daily routines, obligations towards religion and family, as well as financial dealings (Johnson & Aly-Sergie, 2014). The primary sources of these teachings are from the

Quran - the official religious text of Islam – as well as the Sunna, which was developed by the

Prophet Mohammed. However, religious scholars, or sheikhs (who happen to share the same title as members of the royal family), played a crucial role in redefining these practices in the Hadith which eventually diverged into different schools of Islam, including the Sunni and Shi‘a schools, and also serves to dictate Sharia law (Johnson & Aly-Sergie, 2014).

The image of the ‗father‘ and the image of ‗God‘ are very similar in Islam. Many children from religious families are taught to call the emir bābā Jābir (‗father Jaber‘), who is the authority, or father of Kuwait and who is to receive everyone‘s loyalty and obedience (Tétreault

& al-Mughni, 1995). Patriarchy is seen in the family, society, state, and religion, and man is seen as closer to God while women are often considered as lower class citizens. These religious

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nuances are shared by other Abrahamic religions and have promoted three theological assumptions to erect male religious, cultural, and legal superiority (Hassan, 2002). The first is that God‘s primary creation was man rather than woman and therefore women are ontologically secondary and inferior to men. The second is that the women (not men) were responsible for man‘s expulsion from the Garden of Eden, therefore the dominant perception is that ―all daughters of Eve‖ should be approached with caution and contempt (p. 138). The third is that a woman‘s existence is purely instrumental since she was created both from man (from his rib, as the tale goes), and also for man. For these reasons, the Quran, Sunnah, and Hadith have all primarily been interpreted by Muslim men who defined the ontological, theological, and sociological status and identity of Muslim women.

Interestingly, the Kuwait constitution allows for women‘s political rights and ―supports the principle of equality regarding the rights of men and women in all areas, including politics‖

(Al-Mekaimi, 2013, p. 54). This is based on earlier teachings of the prophet and Quran (Chapter

2, verse 187, as cited in Meuleman, 2002) that state both men and women are equal and should be treated with the same respect. The Hadith (which was written by religious scholars generations after the death of the prophet), however, stipulates that a woman‘s presence in men‘s public space is dangerous since al-shaytān (Satan) is bound to be present where men and women are alone (Hassan, 2002). Additionally in the Surrah, men are qawwāmūn (‗rulers‘ or

‗managers‘) and each man is equal to two women (Surrah 4 [al-Nisā]: 34, in Hassan, 2002).

Similarly, according to the prophet (and in contrast to previous interpretations of the prophet‘s teachings), women are inferior in terms of their bodies (since it is a sin to pray while menstruating), as well as inferior in terms of their minds since they intellectually considered to be less than men (Surrah 2 [al-Baqarah]: 282, in Hassan, 2002). The inconsistencies present in

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Islamic texts are highlighted by the fact that Islam and Islamic law are both highly contradictory in nature. In Kuwait, this was partly reflected by the enactment of Election Law 35 in 1962, after which women became restricted in their right to vote and running for office was offered only to men even though this contravenes Kuwait‘s constitution. What‘s troubling is that private citizens have no legal right to challenge the illegitimacy of any law, regardless of how unconstitutional it is (Al-Mekaimi, 2013). Therefore even though Kuwait‘s constitution states that Kuwait is democratic, in practice, the legal system can act quite differently and mostly functions as a dictatorial, race-based, theocratic monarchy.

Although religious groups in Kuwait were primarily involved with philanthropic activities until the 1950s, they began redefining civil life through Sharia, which clearly facilitates the enactment of a patriarchal regime. Since men both legally and culturally hold more moral and social authority in Kuwait, a woman‘s testimony is not as valid as a man‘s in court; specifically, it is only half of a man‘s (which is based on the Surrah‘s and Hadith‘s notion that one man is equal to two women, as we saw earlier; Hassan, 2002). In this way, Sharia law justifies inhumanity and female oppression. This is further reflected by the fact that women‘s rights and benefits are tied to being either the wife or daughter of a male Kuwaiti citizen; therefore, Kuwaiti women are, in theory and practice, second class citizens in their own country (Meuleman, 2002).

Another example of how a woman is treated as a second class citizen in Kuwait is that a child born to a Kuwaiti man and non-Kuwaiti woman will be considered a Kuwaiti citizen, however a child born to a Kuwaiti woman and a non-Kuwaiti man is considered to be a foreign resident and does not have the same rights as other Kuwaiti citizens (Tétreault & al-Mughni, 1995;

Meuleman, 2002). In other words, patriarchal bloodlines are given more importance than matriarchal ones.

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Political empowerment is thought to have significantly increased in Kuwait since women are entering executive positions in the military and parliament. However, Kuwait is still currently among the bottom 10 countries in the world to have closed their gender gap, and therefore has very low overall gender equality (World Economic Forum [WEF], 2015). A recent U.S. report also praised Kuwaiti governance by stating that ―Kuwait‘s political system could service as a model for the Middle East‖ since it has ―successfully incorporated secular and Islamic political factions‖ (Katzman, 2015, p. 2), however there is strong evidence that rejects this notion and shows democracy in Kuwait to be a farce. For instance, the United Nation‘s (UN) attempt to enforce the Convention on the Elimination of All Forms of Discrimination Against Women

(CEDAW) in Kuwait was largely unsuccessful as Kuwait maintained reservations to the articles concerning ‗equal rights with regard to nationality‘ and ‗equal rights on guardianship and adoption‘ (United Nation‘s Children‘s Fund [UNICEF], 2011, p. 2). In practice, this means that

Kuwaiti nationals have more power during a criminal hearing in court than foreigners and men have more legal authority than women with regards to childcare.

The lack of women‘s rights are further elucidated by the fact that, unlike a Kuwaiti man, a Kuwaiti woman is not granted social support (e.g., in the form of subsidized housing) from the government if her husband or father can financially support her (Tétreault & al-Mughni, 1995;

Meuleman, 2002). Therefore, women are religiously, legally, and culturally under the constant

‗protection‘ (i.e., they are the property) of male relatives, therefore the state is effectively acquitted from any responsibility to support a woman. This means that women cannot legally leave abusive situations and seek assistance from the state. The fact that fathers have more custody rights over children than mothers also means that children are unable to leave abusive situations. The UN proposals to change these laws were rejected in Kuwait on the grounds that

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they are incompatible with Sharia law and cultural norms – both of which promote and reinforce patriarchy and other discriminatory practices (Johnson & Aly-Sergie, 2014; UNICEF, 2011,

Wills, 2013). With the exception of some feminist Muslim scholars who have voiced their protests against male dominance in the Arab world (e.g., Al-Mekaimi, 2013; Al-Mughni, 1996;

2010; Hassan, 2002), Muslim women have historically accepted the roles defined for them passively in fear of being punished. However no studies to date have examined the immediate and long-term social and psychological effects of these laws in Kuwait.

Arguably, the reasons for U.S. support for Kuwaiti governance are related to their dependence on Kuwait to secure the Persian Gulf region (i.e., Iraq and Iran) by stationing U.S. military personnel in Kuwait (which is largely financed by the Kuwaiti government; Katzman,

2015), as well as the fact that Western nationals are not as vulnerable to the same inequalities or human rights violations as other foreign nationals. Nevertheless, since Sharia law continues to be a controversial subject, current political debates are related to whether or not Sharia law can coexist with democracy since Kuwait claims to be a democratic state under Article 6 of their constitution (Johnson & Aly-Sergie, 2014, ―The Constitution of The State of Kuwait‖, 2014).

Although Kuwait is legally conservative and patriarchal, Kuwait‘s rapid exposure to the

West and increases in levels of higher education may be contributing to younger Kuwaitis becoming more socially and culturally progressive, which may also result in them becoming more critical towards a religious legal system (e.g., Scull, Khullar, Al-Awadhi, & Erheim, 2014).

Progress has also been made on the political level, as women gained the right to vote in 2005 – largely (and ironically) owing to support from Kuwait‘s autocratic executive rather than its

‗democratic‘ parliament (Al-Mughni, 2010; Shultziner & Tétreault, 2011; The CIA World

Factbook, 2016; Wills, 2005). This was only made possible by Islamist women activists in the

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1990s who strongly campaigned for equal political rights in Kuwait. Although Kuwait became more conservative after the war, Kuwaiti (particularly female) survivors gained more political consciousness and agency as they became involved in resistance activities during the war and took the responsibility of empowering their communities (Al-Mughni, 2010). As one female survivor said, ―the occupation taught me that men and women can be partners in political life‖ and that ―the right to political participation became one of my top priorities‖ (in Al-Mughni,

2010, para 24). Additionally, the numbers of ‗liberal‘ MPs have been increasing in Kuwait, however these MPs can be susceptible to religious condemnation (e.g., for publicly announcing their support for legalizing alcohol; Moftah, 2015). Despite some progress in the sociopolitical system in the last decade, the repeated dissolving of the Kuwait National Assembly makes it difficult to make changes to the law, therefore – apart from granting women the right the vote – the legal system has remained relatively stagnant during the last two decades (Katzman, 2015).

Kuwaiti Culture

Religion is the bedrock tradition in Arabian countries therefore religion and tradition are almost synonymous terms when discussing Kuwait. Social order and culture in Kuwait have also largely been built on nationalism, female subordination and patriarchal ―tribalism‖ (Meuleman, 2002).

Additionally, in Kuwait‘s constitution, it is not the individual, but the family that is defined as the basic unit of society; as such, Kuwaiti society is essentially a multilevel hierarchical family unit with the emir at its zenith (Tétreault & al-Mughni, 1995). Although Kuwait claims to be a democratic state, in a Marxian view, Kuwaiti society is inherently class-based as the state acts as a separate entity and imposes state dominion over classes that are on the lower rungs of the socioeconomic, political, and ethnic ladders. This societal class system is fundamentally biased towards Kuwaiti men and has a tendency to bleed into its very unique culture that is otherwise

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characterized by high levels of support and solidarity owing to its ―collectivistic‖ nature and ancient Islamic roots (Tétreault & al-Mughni, 1995; Scull et al., 2014).

Many discussions about culture and politics in Kuwait occur in the diwaniya, which means both ‗physical space‘ and ‗type of gathering‘ (El-Kebbi, 2013). The diwaniya is very unique to Kuwaiti culture and is present within many households or standing on their own next to mosques or other public spaces. It is a large room (or section of a house), separated from the rest of the space, has lots of seating and almost resembles the salons during the French

Enlightenment. This is where men come together in the evening and discuss, debate, and have open dialogues about recent national and international events and politics (Clawson, 1997;

Stephenson, 2011). The diwaniya is a form of informal political institution and civic culture, and can include Arab men from all levels of society – from civilian to ministerial meetings and between royal family members (Clawson, 1997; El-Kebbi, 2013). Ironically, the diwaniya is referred to as the one factor that sets Kuwait apart as the most democratized of all Middle

Eastern countries even though it is rare for women to take part in diwaniyas. The fact that females are generally excluded means that their role in political discourse is limited relative to men‘s; therefore, some feel that Kuwait is not as democratic as it is portrayed or likes to pretend

(e.g., El-Kebbi, 2013).

Kuwaiti culture has experienced some dramatic shifts since the 1950s, however one aspect that stood the test of time is that Arab-Muslim populations, including Kuwait, tend to be highly collectivistic and have very strong social capital (Scull et al., 2014). In other words, individuals in a community are generally bound by mutual obligation, and much of an individual‘s identity, support, and resilience are derived from very strong family ties and their religious communities (Ciftci, 2010; Oyserman et al., 2002; Scull et al., 2014). Although these

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factors tend to strengthen individuals and communities alike, individuals are more often than not socialized to meet familial expectations that can sometimes go against the individual‘s best interests and overall wellbeing (Scull et al., 2014). Oftentimes, this conformity is highly enforced; therefore, any behaviours that deviate from cultural norms are frowned upon and can limit marital prospects and lead to other forms of social exclusion (Erickson & Timimi, 2001;

Scull et al., 2014). Although families are a significant source of strength and support in Kuwait and other Arab countries, they can also be highly patriarchal and therefore a source of oppression

(Castillo, 1997; Scull et al., 2014). Additionally, since an individual‘s (especially a girl‘s or woman‘s) reputation and social standing reflects on the whole family, any issues (such as having premarital sex or having a family member with a mental disorder) that could damage one‘s reputation, are generally kept within the family (Scull et al., 2014). Secrecy, gossip, and the fear of shame, therefore, play crucial roles in maintaining the status quo in Kuwait, making family structure rather complex, contradictory, and elusive in nature (Scull et al., 2014).

The youth of Kuwait (as with many other Arab countries) have a reputation of being highly reliant on both family and state financial prosperity and therefore lacking motivation in the workforce (Tétreault & al-Mughni, 1995). This increased dependency in Kuwait is owing to overly generous welfare and social assistance programs which decrease incentives to work, result in large amounts of unsupervised free time, and provide many families more in welfare payments than they could otherwise earn as full-time employees (Al-Kandari, Yacoub, & Omu, 2001;

Tétreault & al-Mughni, 1995). These factors also reinforce patriotism and the class system as migrant workers are looked down upon, and help maintain mutually antagonistic boundaries between the elite and lower class, and Kuwaitis and non-Kuwaitis (Tétreault & al-Mughni,

1995). Although the psychological impacts of these factors have not been qualitatively assessed

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in Kuwait, there is some research that suggests that unsafe substance abuse is very common among Kuwaiti youth owing to excess amounts of wealth and free time combined with the lack of adequate health information and education (Al-Kandari et al., 200; Barrett & Behbehani,

2003; Khullar, Scull, Deeny, & Hamdan, 2015a; Khullar, Deeny, Scull, & Hamdan, 2015b).

How these factors affect older adults, women, and children, however, have yet to be examined, along with other possible contributors to substance abuse in Kuwait.

Introducing Mental Healthcare to Kuwait

As we saw in Chapter 3, disaster zones tend to attract mental health programs from the

West, after which Big Pharma typically delivers their sales pitch. We also saw that introducing

Western mental healthcare is more feasible when local mental health establishments can be easily convinced of Western treatment plans; in other words, with no mental health system – and therefore no practicing mental health professionals – global pharmaceutical agencies have no launching pad to allow their operations to prosper.

According to the Kuwait Center for Mental Health (KCMH, 2010), the first mental health premise was established in Kuwait in 1940; this became the Psychiatry and Neurology Center in

1949 and renamed to the Psychological Medicine Hospital in 1959 (which is now the KCMH).

The first Department of Psychology and Education was established when Kuwait University opened in 1966 (Ahmed, 1992). In 1972, the Ministry of Education began employing Kuwaiti and other Arab psychologists and trainees as counsellors within the Department of Psychological

Services, after which they began publishing research projects (Ahmed, 1992). Some of the earliest published studies on mental health in Kuwait began in the 1980s (e.g., Al-Ansari, El-

Hilu, El-Hihi, & Hassan, 1990; Chaleby, 1985; El-Hilu et al., 1990) while the DSM III and its subsequent text revision became international best sellers (Greenberg, 2014). It was during this

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time that psychiatric diagnoses became common place in Kuwait, particularly with foreign domestic workers (e.g., El-Hilu et al., 1990) and female inpatients at psychiatric wards (e.g.,

Chaleby, 1985). The primary purpose of conducting psychological studies during this time was to obtain graduate degrees for local students (Ahmed, 1992). However, another purpose – which

Kuwait shared with other developing countries (see Chapter III) – was to establish the budding mental health system as reputable according to international (i.e., North American) standards by utilizing the diagnostic tools of the DSM and ICD (e.g., Al-Ansari et al., 1990; Chaleby, 1985;

El-Hilu et al., 1990). Similar to other developing nations (e.g., Sri Lanka – see Chapter III),

Kuwait received a great deal of its inspiration for mental health research from Western models.

Kuwait was never a major research playground for psychologists until after the 1990 invasion, which happened to occur around the same time that PTSD was, as we saw in Chapter 3, where all ―the action‖ was in mental health research at that time. Researchers began publishing census studies on PTSD in children and adults in British and American journals (e.g., Bisson,

Searle, & Srinivasan, 1998; Nader et al., 1993; Nader & Fiarbanks, 1994). Some researchers continued this tradition well into the following decade (e.g., Al-Turkait & Ohaeri, 2008; Llabre

& Hadi, 200) and used survivors of the invasion to validate existing American measures of various psychological constructs and therapeutic modalities (e.g., Abdel-Khalek, 2004; Al-

Balhan, 2006; Nader & Pynoos, 1993). Even researchers who alluded to the Western bias in existing psychometric tests and explored indigenous methods of coping aimed to ―build a predictive model of national traumatic reactions… that could be useful in subsequent national traumas‖ (e.g., Al-Naser, Ridha, & Figley, 2005, p. 1), thereby succumbing to the Western scientific notion that all good research must have predictive value. Only one study examined how indigenous copies strategies (e.g., Islamic forgiveness attitudes) foster better mental health

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outcomes among Muslim survivors of war and promoted a more culturally appropriate approach to mental health care (see Scull, 2011); other than that, there was very limited research that focussed specifically on resilience after the invasion.

Before the invasion, mental health provisions in Kuwait were generally poor since there was very little staff and virtually no demand for mental healthcare. The war, however, opened the door to more psychological inquiry and served to afford academic and professional progress and rationalize the expansion of mental health services. After Kuwait‘s liberation, ―new programs were added‖ at the Psychological Medicine Hospital to treat the ―epidemic of PTSD‖

(KCMH History, 2010, para 7); this is when Kuwait began witnessing a sharp increase in the numbers of psychiatrists, psychologists, social workers, residents, nurses, and (not surprisingly) pharmacists, after which it was only a matter of time before psychiatric facilities would begin increasing their operations.

Although there is a dearth of literature that identifies exactly when psychiatrists first began prescribing psychotropic drugs in Kuwait, Bilal‘s (1989) study demonstrates that ‗Big

Pharma‘ had already planted themselves in Kuwait in the late 1980s when Kuwaiti mental health professionals began using the DSM. He examined iatrogenic (i.e., clinician-induced) benzodiazepine dependence among Kuwaiti psychiatric inpatients, and identified local psychiatrists as ―less circumspect about prescribing benzodiazapines‖ to the extent that dependence ―superseded addiction to illicit drugs and alcohol‖ in Kuwait (p. 1,138). Fido and

Razik‘s (1992) study also alluded to the fact that about a third of the psychiatric inpatients in the early 1990s were haphazardly prescribed psychotropic medications, and more than half of them were taking four or more prescription psychotropic drugs simultaneously. Regardless of the diagnosis they received, all patients were prescribed neuroleptics (antipsychotic drugs used to

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treat schizophrenia) and given excess doses of anticholinergic drugs (to promote sedation). There was also a clear lack in ethical prescribing at the Psychological Medicine Hospital since many of these prescriptions were administered under a general nurse‘s, rather than a physician‘s guidance.

By the early 1990s, Kuwait spent approximately 200 million dollars annually on medication alone, approximately 15% of which was psychotropic (Kuwait Ministry of Public

Health, 1993). In 1999, Kuwait officially registered itself under the International Conference on

Harmonization (ICH) as an official pharmaceutical distributing agent (ICH, n.d.). Reflecting back to the argument in Chapter III, this is more indicative of ‗Big Pharma‘s‘ biomarketing success rather than an actual advancement in mental health services in Kuwait since psychiatrists in Kuwait recently received negative patient reviews for maltreatment, confidentiality breaches, and oppressive language (Scull et al., 2014). It is also clear that some psychiatrists in Kuwait strongly endorse the consumption of psychotropic medication; Dr Adel al Zayed publicly suggested to general practitioners, for example, ―not to hesitate to give anti-depressants, even if unsure‖ (Salem, 2010, para. 10). He summarized the general consensus on psychiatry by the

Kuwaiti community: ―how can we be depressed, we pray all the time; to hell with psychiatrists and Freud‖, to which he responded, ―anyone with a depressed mood, loss of interest or pleasure, is depressed, by definition‖ without considering any of the social or societal factors that elicit depression in Kuwait, or viewing everyday sadness as normal (para. 11). Despite the local resistance to psychiatry, some psychiatrists in Kuwait are pushing for psychopharmacotherapy in

Kuwait and it appears that the local clinicians will continue to find ways to increase patient visits. What‘s interesting, however, is that physicians in the public sector are given a fixed salary, and do not appear to have a financial advantage (at least from their patients) for

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prescribing medication. Therefore, the incentives (financial or otherwise) for pushing psychopharmacotherapy in Kuwait still remain to be explored.

The Current Mental Health System in Kuwait

In order to expand the reach of services to a wider community and appear more holistic, the

Psychological Medicine Hospital was renamed the Kuwait Center for Mental Health (KCMH) in

2013 (Almazeedi & Alsuwaidan, 2014). The KCMH operates under the jurisdiction of the

Kuwait Ministry of Health and is currently Kuwait‘s largest mental health facility and the only public mental health hospital in Kuwait. The KCMH now provides in-patient and out-patient medical (e.g., haematology and biochemistry laboratory testing), psychiatric, psychological, and social work services and is the only establishment in Kuwait that offers in-patient mental health services. The KCMH provides treatment for children, adolescents, and adults, and offers a wide range of addiction, geriatric, forensic, and emergency services (e.g., in the case of illicit drug overdose and suicide attempts) to the Kuwait community. All treatment is free to Kuwaiti citizens and all foreigners and their dependents holding resident permits (which are generally obtained with a Kuwaiti work visa; Scull et al., 2014). The KCMH is affiliated with Kuwait

University and closely collaborates with faculty to provide medical training to psychiatric residents and nurses. It has approximately 700 beds distributed in separate male and female wards and also has a recreational facility consisting of a large gymnasium and swimming pool for in-patients.

According to Al-Sayer (2013), other public mental healthcare services in Kuwait include three non-profit organizations for children (e.g., Centre for Child Evaluation and Teaching) and the disabled (e.g., The Kuwaiti Society for Guardians of the Disabled) that rely on charity. In addition to the KCMH, other state-funded organizations include the Developmental Pediatric

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Unit at the Al Sabah Hospital and the Social Development Office. In the private sector, there are currently 21 different registered centres for mental health, including single-clinician private practices – none of which are governed by any licensing bodies to ensure ethical service delivery. These figures do not include therapists who practice from their homes.

There have been very few evaluations of the mental health services in Kuwait. Alqashan and Alzubi‘s (2009) research with 75 employees at the Social Development Office (SDO) reported that most mental health providers practice with only a Bachelor degree (53%). What‘s more alarming is that there were more high-school diploma graduates (27%) than social workers with graduate degrees (20%) providing mental health care at the SDO. Suffice it to say, the majority of the participants reported high feelings of anxiety and dissatisfaction with their jobs

(62%), which was attributed to burnout experienced as a result of secondary trauma after being repeatedly exposed to distressing cases, as well as the lack of training and experience with vulnerable populations. Consequently, the Kuwaiti community has developed very negative perceptions of mental healthcare, the most common one being, ―you cannot trust [mental health clinics]… If you go there, you will become more crazy‖ (in Scull et al., 2014, p. 291). For this reason, most individuals in need of mental health services will seek support from their family practitioners, who are generally not trained to provide adequate counselling (Almazeedi &

Alsuwaidan, 2014; Scull et al., 2014).

A recent qualitative analysis of individuals‘ experiences and perceptions of mental healthcare in Kuwait alluded to how heavily stigmatized it is (Scull et al., 2014). Owing to the lack of awareness and education about mental health, individuals primarily base their perceptions on second-hand information (e.g., a friend, family member, or the media). This, combined with various cultural factors such as the importance of reputation, and a high propensity for gossip,

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individuals seeking treatment do so in secrecy or forego treatment altogether in fear of bringing shame onto themselves and their families. Additionally, individuals who had previous experience with the mental health services in Kuwait, more often than not, had very negative experiences with their clinicians. For example, one patient complained that ―they just test for how smart you are, but when you need to talk… They don‘t listen‖ (p. 291). Similarly, one participant criticized the psychiatric services in Kuwait as being practiced ―on an authoritarian level‖ because ―you can get admitted into the mental hospital for being gay‖ (p. 292). Another participant summarized his experience with his psychiatrist:

My psychiatrist called one of his patients… I think she was deeply manic or she was having an episode of some sort. She interrupted our session and he told me, ‗don‘t worry, that‘s one of my patients, but you‘re not like her. She‘s crazy‘. Quote… This is exactly what he said: ‗you are not like her, she‘s crazy‘. This is also the same man who initially tried to push the Quran on me (p. 292).

Although Scull et al‘s (2014) study identified that ―much of daily life is viewed through the lens of Islam‖ in Kuwait (p. 292), there is reason to believe that there is an underlying social pressure to appear religious – especially among younger, more progressive Kuwaitis. This becomes an issue in a therapeutic setting when there is clear disparity between the patient‘s and clinician‘s religious beliefs, especially when therapists try to impose their own ideologies onto their patients. Nonetheless, the study also alluded to the fact that Islam and mental health care can be mutually supportive:

The way I understand Islam, is if you fall and break your leg, you have to get a

cast. If you have a psychological issue, you have to go seek help. There‘s nothing

in Islam or Hadith that tells you not to go and seek help. (p. 293)

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Researchers and clinicians have identified that stigma, a lack of mental health awareness, and a lack of mental health legislation (e.g., confidentiality rights) are currently the biggest barriers to seeking mental health care in Kuwait (Almazeedi & Alsuwaidan, 2014; Scull et al.,

2014). For this reason, mental health professionals and scholars have started to develop mental health outreach programs and awareness campaigns in an attempt to educate the community. One of these programs, called SPEAK (Standing for Psychological Education and Awareness in

Kuwait) was developed by two Kuwaiti sisters, Dalal and Alaa Al Homaizi, who are currently pursuing Ivy League graduate degrees in psychology in the U.S (see Al Homaizi & Al Homaizi,

2014). The goals of SPEAK along with other outreach programs are to reduce the stigma of mental illness, fight for equal rights for individuals with mental disorders/disabilities, campaign for the recognition of psychology and psychiatry as necessary health fields and promote research and education in mental healthcare. The sisters also coined the term psy-lence to denote the silence and secrecy associated with mental illness. Additionally, mental health centers in Kuwait have started posting educational material on OCD, depression, schizophrenia and healthy cognitive functioning on social media sites such as Facebook (e.g., The Kuwait Center for

Mental Health, 2013).

Although the goal to promote mental health in Kuwait is noble and has the potential to benefit many people, Chapter 3 highlighted the issues with increasing ‗mental health literacy‘ in countries. To reiterate, mental health literacy and advocacy typically begin as moral assertions, whereby mental healthcare is marketed as a philanthropic service and individuals are told that they are doing themselves a disservice by not seeking professional care during times of distress

(Applbaum, 2006). Previous studies alluded to some valid critiques about psychiatric services in

Kuwait, however it appears that the events in Kuwait are beginning to echo what happened in

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Japan and China (see Chapter III) before psychiatric services (and therefore the use of psychopharmacotherapy) expanded. Advocates critique the local system and the ‗take for granted‘ attitude that Western mental healthcare is situated within a cultural and political ideology and is highly value-laden. In effect, they begin promoting and destigmatizing mental healthcare without fully exploring the lived experiences of mental health and illness in the native population, after which Western definitions of mental disorders enter public consciousness, potentially causing people‘s explanatory models of illness to change (Applbaum, 2006). That psychiatry is given more prominence in Kuwait (as well as the fact that it is subsidized to citizens and foreigners holding a work and residence permit) could pose a major risk for the

Kuwaiti community as it is likely falling into the same fatal trap as Japan, where psychopharmaceutical sales suddenly began increasing as more and more people sought mental healthcare.

Unfortunately, no studies to date have examined the economic drivers of mental healthcare in Kuwait, and there is currently no published data to consistently track annual psychopharmaceutical sales in Kuwait. However, given that the manpower in the public psychiatric hospital in Kuwait has been steadily increasing since the 1990s (currently employing

95 doctors and 729 nurses), it is safe to assume that the demand for mental health services in

Kuwait has been increasing over the past two decades, especially with its recent anti-stigma campaigns (Kuwait Ministry of Public Health, 1993; 2013). Despite the different types of mental health and social work services (e.g., family therapy, group work, and discharge planning) provided by the KCMH, it appears that psychiatry and clinical psychology are their primary methods of treatment – at least within the public sector (KCMH, 2010). Consultations generally include clinical testing such as intelligence, cognitive, and personality tests, followed by

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counselling, psychotherapy and the prescription of psychiatric medication. Additionally, since

Kuwait has been publishing studies that explore effective ways to maintain patient adherence to psychopharmacotherapy (e.g., Al-Saffar, Deshmukh, Carter, & Adib, 2005; Fido & Husseini,

1998), it is safe to assume that it is the preferred method of providing mental health care to the

Kuwaiti population. Finally, since psychiatry falls under the Ministry of Health unlike other psychological services (e.g., counselling), psychiatric consultations and filling prescriptions for many psychoactive drugs are subsidized for all residents and citizens; therefore, individuals seeking mental health care who cannot afford to pay for private counselling out-of-pocket have no choice but to seek state-subsidised psychiatric services and the consumption of the psychotropic medication as a first line of treatment.

Other than the study conducted by Scull et al. (2014), there is no research that explores how the lack of mental health legislation affects the perceptions of mental health and illness in

Kuwait. There is also no research that looks at the lived experiences of mental health and illness from the perspectives of mental health service users, clinicians and members of the Kuwaiti community. Since Kuwait is, in Jorm‘s (2012) words, beginning to increase its ‗mental health literacy‘, it is also important to shed light on the economic and political drivers of Kuwait‘s mental health system. Additionally, since Scull et al‘s (2014) study also highlighted that many patients prefer seeing Western-born therapists as they are perceived as being more progressive, it is important to explore how cultural disparities in doctor-patient relationships affect the therapeutic process. It is also essential to explore the phenomenological experiences of mental health and illness to inform culturally sound, and evidence-based policy initiatives that may improve mental health service delivery in Kuwait.

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Given that Kuwait is a WHO member state and scores relatively low on overall health indexes, the WHO (2014) is now attempting to ―identify the health priorities in the country‖ and

―have stronger impact on health policy and health system development‖ in Kuwait (WHO, 2014, p. 4). We saw in Chapter III that the WHO has strong alliances with pharmaceutical companies who wait for opportunities such as these to support mental health anti-stigma campaigns in order to market psychotropic medications to foreign populations. Therefore it is crucial for health care providers and consumers to be vigilant of the changes many physicians under the Kuwait

Ministry of Health want to see, what ideological umbrella they conceptualize mental healthcare under, what their perspectives are on the determinants of mental health and illness, and the extent to which these perspectives overlap with those of non-medical mental healthcare providers (e.g., psychologists, social workers, and counsellors) and mental health service users in Kuwait. The purpose of this study was to navigate the mental health system in Kuwait in an attempt to explore all these phenomena. The next chapter will describe the theory and methodology used.

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Chapter V. Methods: Using Critical Theory to Inform Qualitative Research

In the previous chapters I highlighted many of the problems associated with North

American mainstream psychology - i.e., the paradigm that is the mainstay version taught at universities and that most researchers and clinicians practice. I also emphasized that much of mainstream psychology, which is grounded in North American political ideologies, can be particularly problematic when applied to other cultures as it often provides a very narrow, institutionalized portrayal of humanity and both reifies and globalizes the idea of the American psyche. In this chapter I provide an overview of the theoretical roots of this line of thought and discuss an alternative psychology that is neither frequently taught nor practiced because it is grounded in philosophies that are antithetical to forces that maintain inequality of socioeconomic and political power. In the first part of this chapter, I critique the notion of the Cartesian mind which forms the backbone of mainstream mental health practice. In the second part, I discuss the philosophical and theoretical underpinnings of Critical Psychology and the rationale behind using this approach to study mental healthcare in the non-Western world. In the third and final part of this chapter, I describe how critical theory can radicalise qualitative research methods and the specific procedures I used to navigate the mental health sector in Kuwait.

The Cartesian Mind

Descartes‘ philosophy of human existence, cogito ergo sum (I think therefore I am) quite aptly summarizes how we view consciousness today (Danziger, 1997; Orange, 2001). Within the

Cartesian model we can separate our rational consciousness from our irrational emotions and

―ground all knowledge in certainty, in clear and distinct ideas‖ that will always hold true regardless of social, historical or cultural factors (Albuquerque, Deshauer, & Grof, 2003, p. 286).

Descartes was the first to challenge the three ancient forms of knowing as a necessary step

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towards the development of the harder sciences (Gravetter & Forzano, 2012). These three forms of knowing were tenacity (believing something is true because it was practiced for generations), authority (blindly accepting what an authority figure has said), and intuition (believing something that is not supported through objective measures). Although Descartes is credited for his vast contribution to the development of an ‗objective‘ scientific method, his work became highly contradictory as his latter followers merely replaced God with science (and the ‗soul‘ with the ‗mind‘) and endorsed the three forms of knowing that he initially challenged.

Danziger (1997) described how Descartes‘ theories unfolded from Aristotle‘s notion of the

‗soul‘ and the Medieval Christian concept of the ‗will‘. Aristotle distinguished between five powers of the soul: the power of nourishment, the power of sensing, the power of movement, the power of appetition (desire), and the power of thinking. To Aritstotle, plants were only capable of the first power, non-human animals were generally capable of the first three, while only humans were capable of all five powers. These powers were far more metaphysical than rational; each power represented an affordable, human desire, fully attainable by the soul. In this way,

Aristotle saw the human soul as more agentic than Descartes did. Additionally, there was no clear distinction between the mind and the body, and neither were held in more positive regard than the other; they each strove to achieve what was ‗good‘ for the soul.

In Medieval Christian theology, however, the soul was connected to God‘s will, and therefore emphasized self-restraint over appetition (Danziger, 1997). Therefore religion essentially changed the meaning of humanity; from being metaphysical entities, we now became individuals who had to abandon the undesirable appetites of the soul and focus on our will

(during the industrial revolution, the idea of motivation became important when our wills failed us). Religion did not emphasize the difference between cognitions (of the mind) and passions (of

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the soul) per se; rather, it distinguished between natural (good) and unnatural (bad) manifestations of the soul, leading to the idea of stoicism and asceticism, or the ideal of rigid self-control. In this way, some Christian theologists distorted the ancient Greek view of agency to rationalize their own agenda for control over civil society (Danziger, 1997).

Descartes was heavily influenced by both ancient Greek philosophy as well as religion and completely radicalized the notion of bodily passions in The Passions of the Soul (1649)

(Descartes, 1989; Danziger, 1997). These passions were now changed to both perceptions as well as actions of the soul (Descartes, 1989), which meant that the soul was capable of perceiving these passions, and the body was responsible for exhibiting observable behaviours which were now, owing to the religious norms at the time, viewed as either good (moral) or bad

(passionate or immoral). To Aristotle, there was no ‗motivational drive‘, therefore the concept of voluntary as opposed to involuntary action (reiterated later as conscious and unconscious drives in psychoanalysis) did not exist. Without this line of thinking, there was no logic behind the struggle for self-management, because there was no separate ‗self‘ to manage. Therefore, while

Aristotle described humans as metaphysical, coexistent and active in our natural world,

Descartes, while defending the knowledge of natural science, strengthened the budding religious notion of the good soul (i.e., the good mind) and the bad body (Danziger, 1997).

Descartes also, somewhat awkwardly, went to the extent of bridging the gap between reason and feeling by coining the term intellectual emotions, which loosely describes the contemporary notion of emotional intelligence, or our ability to think about our emotions rationally with the goal of exhibiting more adaptive behaviour (Descartes, 1989; Teo, 2009).

Emotional intelligence – or other revisions of it, such as mindfulness (see Schutte & Malouff,

2011) – have now become almost necessary and irreversible aspects of our cultural self-

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understanding. However, rather than recognizing that these self-concepts are cultural and socially constructed, mainstream Psychology is operating under the assumption that the self is a natural mode of existence rather than an ideological one that was largely developed to service those who created it (Teo, 2009).

With the exception of more critically oriented approaches such as feminist therapy, narrative therapy, critical psychology, community counselling and multicultural counselling and therapy, the most popular approaches (e.g., cognitive behavioural therapy, psychopharmacology, and arguably psychoanalysis) are grounded in this Cartesian model (Prilleltensky, Pelleltensky,

& Voorhees, 2009). In fact, Descartes played more than an indirect role in shaping the course of modern mental health care; he explicitly suggested that therapy should include individual mind therapy (which closely resembles modern cognitive-behavioural therapy, or CBT) as well as body therapy (i.e., modern day psychiatry; Albuquerque et al., 2003), both of which currently dominate the mental health field today.

Orange (2001) outlined eight separate pillars of the Cartesian mind that present themselves in contemporary mental health care, which I collapsed into the three domains of dualism, logical positivism, and representationalism. As discussed in Chapter I, dualism is the theory that various phenomena, constructs and experiences exist in opposites (e.g., mind versus body and internal versus external). Logical positivism is a type of epistemological position and suggests that there is a direct relationship between the world and our perceptions of it. It is associated with the correspondence theory of truth, or the notion that the objective properties of phenomena directly determine (i.e., they fully correspond to) our view of them (Willig, 2008).

Representationalism is one of the pillars of cognitive psychology and suggests that our minds act as vehicles between external stimuli and internal perceptions. These perceptions may or may not

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represent ‗true‘ reality, since our minds interpret what we see according to models (schemas) we have developed throughout our lives (Orange, 2001).

Dualism is seen in terms of self-enclosed isolation, the subject-object split, and inner psychic reality versus outer material reality. Self-enclosed isolation is the view that the mind exists in isolation, either accurately apprehending or distorting external reality. Orange (2001) described this notion of the mind as a ―heroic myth‖ that permeates Western thought, as the

―autonomously self-regulating ego‖, or Freud‘s ―drive energies‖ (p. 289), giving the mind a peculiar grandiosity. Symbolically, the Cartesian mind resembles the lone wolf – or in fantasy terms, Clint Eastwood‘s ‗The Man with No Name‘, Rambo, Captain America, G.I. Joe, Indiana

Jones, or any number of American heroes, existing in isolation, in search of the ‗truth‘; the quintessential ideal of what, metaphorically, Western mental health care has become (see

Chapter III: Glorified martyrdom). It is the notion that each mind (or individual) is responsible for itself (or him or herself). The Cartesian mind is, for all intents and purposes, a symbol of the

American dream. Clinicians with this isolated-mind view can describe their patients as narcissistic or perfectionistic; that they are denying, projecting, identifying, over-identifying, or being ‗noncompliant‘ (Anderson & Danis, 2006). By viewing the mind as self-enclosed we are inadvertently expressing contempt towards a patient or client, rather than validating their response as a form of resistance towards acts of violence, oppression, or any other lived social experience that was not conducive to their sense of agency – which is, more of than not, what brings people to therapy (Anderson & Danis, 2006; Coates & Wade, 2007; Wade, 1997).

Related to the notion of self-enclosed isolation in Cartesian thought is the subject-object split, or in psychoanalytic terms, psychical versus external reality. Traces of this view exist today in how we typically understand interpersonal – including therapeutic – relationships, which we

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analyze in terms of how ―unrelated monads‖ interact with each other (Orange, 2001, p. 291). As

Orange continues to describe, the inner-outer contrast is the foundation of ego psychology; to

Freud, the inner psyche was healthy in as much as it adapted to the outer world. This view compromises the therapeutic process as the clinician and client can become entrenched in the process of determining whether responsibility or cause of change resides internally (in the patient‘s mind) or externally (in the patient‘s environment). Again, more often than not, this indirectly has an infantilized view of the patient, because it implies that an individual may be acting maladaptively – including in an environment that may not be conducive to their overall wellbeing. Allan Wade, however, argues for a more ‗resistance‘ based approach, whereby any acts of resistance towards oppression, injustice, or disrespect – regardless of whether they are overt (e.g., being noncompliant) or covert (e.g., dissociating emotionally and imagining a better life) – are healthy, adaptive, and conducive to helping a patient realize that they are in fact resisting some form of oppression, injustice, or disrespect (Coates & Wade, 2007; Wade, 1997).

(In some cases, the therapist may help the patient understand that this behaviour may have been necessary in the past, and asks if they feel that their behaviour may be working against their best interests in the present). This is far more empowering than viewing a patient under the umbrella of a cognitive-behavioural model in which their negative experiences are thought to have adversely transformed their mental ‗schemas‘, causing them to behave irrationally.

Positivism presents itself in the goal for clarity and distinctiveness, or the true-false binary type of knowledge that was initially perpetuated by Galileo (Orange, 2001). This is a form of reductionism because it treats ‗simple‘ psychological principles as natural laws of human behaviour. For instance, it is almost a given in the psychological community that an individual who experiences trauma (stimulus) will feel traumatized and is more susceptible to developing

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PTSD (response). We saw in Chapter III that many Western-trained psychologists and mental health advocates assumed that the tsunami in Sri Lanka would result in a massive wave of PTSD symptoms in the local population, when in fact all it demonstrated was that the local population was very resilient in the face of life-threatening events. This also sheds light on the second positivistic aspect of the Cartesian model: that it relies on top-down, deductive logic which is not necessarily ―empirically‖ driven (i.e., assuming that everyone will have the same response to trauma is based more on misguided logical thinking rather than actual observation). Additionally, the mantra of the psychoanalytic school is that the unconscious drives us, which acts as the premise for all psychoanalytic work. This unconscious mind, however, is isolated, atomistic, and mechanistic and is seen as something that conceals rather than reveals, and it is up to the therapist to help facilitate the patient‘s heroic dive into the hidden reservoir of unconscious feelings and memories to find ―the truth‖, rather than exploring different versions of constructed lived experiences. The absence of temporality is another way the Cartesian model lends itself to positivism. The absence of temporality is seen in the clinical setting when the patient is viewed as isolated in space and time, stripped, or abstracted, from their natural environment (Orange,

2001).

The third domain of the Cartesian mind deals with representationalism, or the notion that our minds can, through sensation and perception, build an internal reservoir of ideas that provide us with a lens or model to view the real world. In contemporary terms, cognitivists call these models schemas. In a clinical setting, representationalist thinking becomes problematic when we try to unravel what is and is not accurately represented. This can make us lose sight of how meaning is co-created (both in and out of the therapeutic setting) and memories are constantly reconstructed. The final pillar of the Cartesian mind that prescribes to representationalism is the

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concept of the ―mind as substance‖. In other words, the mind is reified from something abstract and completely reduced to a commodity; for instance, ―a mind is a terrible thing to waste‖

(Orange, 2001, p. 295). By reifying the mind in this way, psychologists have projected a reality onto the mind that does not really exist and thus have put the mind on a pedestal, by claiming that our minds are the primary sites of our experiences (Castillo, 1997; Orange, 2001; Russon,

2003). In traditional psychoanalysis, these experiences take the form of mental contents such as drives and fantasies, reducing us to the mechanisms of projection, repression, and transference

(Orange, 2001). Again, we see the onus of distress fall on the patient; that whatever their troubles, they are individually caused.

Ultimately, what gives psychiatry (and arguably drug cartels) more power over any other mental health domain is that uneasiness can be anesthetised and ignored; psychopharmacology quickly promises tranquillity when the psyche is anxious, focus when the mind is scattered, and silence of the soul when we turn our anger inward. This anxiety is not an individual one, nor is it a social one; it is an epistemological one that has plagued much of the mental health industry.

The uneasiness we see and try so hard to alleviate is deeply imbedded within the scientific enterprise and the symptoms of mental illness are, in fact, the symptoms of an epistemic crisis. It is this epistemic crisis that is referred to here as the Cartesian anxiety.

In Beyond Objectivism and Relativism: Science, Hermeneutics, and Praxis, Bernstein

(1983), who first discussed the Cartesian anxiety, stated that it should not necessarily be associated with Descartes; it is merely a reflection of the issues and uneasiness that plague philosophy – or the study of epistemology, ontology, and praxis as they pertain to human ethics and happiness. Cartesianism inspired radical criticisms from continental philosophers in the 19th and 20th centuries who began to resurrect Aristotelian views on humanity because the over-

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reliance on science was self-referentially sabotaging. In other words, it reinforced the very authority and tenacity that Descartes fought against. Essentially, the Cartesian anxiety is the uneasiness that permeates those who search for clarity and distinctiveness – or the ‗perfect idea‘

(or the ‗perfect state‘ as proposed by Platonic thinkers). It is representative of the quintessential

American moral panic. This uneasiness is seen more readily when we are faced with the issue of praxis – or the process of putting theory to practice (Bernstein, 1983). Psychology is, for all intents and purposes, the praxis of philosophy. To this end, the next section will discuss praxis in light of critical theory.

Critical Psychology: Phenomenology and Praxis

Unlike mainstream psychology, where the unit of analysis is typically the individual, critical psychology analyses systems and ideologies (Tolman, 1994; 2009). Critical psychologists argue that the ‗perfect idea‘ is an illusion, and searching for clarity, distinctiveness and perfection in human systems is naïve, idealistic, and futile (Fox, Prilleltensky, & Austin, 2009). Critical psychologists also move beyond the sphere of mainstream social psychology by looking at how political, economic, and cultural ideologies and distributions of power shape social bonds and how these social bonds, in turn, shape individuals‘ personal experiences, perceptions, narratives and identity development (Coughlan, 2002; Fox et al., 2009). Rather than borrowing from the natural scientific paradigm, critical psychologists utilize the analytical tools put forth by anthropologists and sociologists (Tolman, 1994). These include qualitative methodologies through which researchers can analyze both verbal and nonverbal behaviour by collecting data in the form of interviews, focus groups, institutional ethnographies, or any medium by which language and power are conveyed. As such, the analysis of language (e.g., discourse analysis) is a central component of critical psychology as it provides researchers with distinct insights into

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how power is communicated within political, economic, and cultural institutions. Since critical psychologists view the individual as a constellation of their social relationships and interactions, and therefore consciousness as an external and social (rather than an internal and individual) process, critical discourse analysis situates language within this broader political, economic, and cultural trajectory (Cooley, 1902; Coughlan, 2014; Mead, 1925; Russon, 2003).

As we saw earlier, all the domains of the Cartesian model are grounded in the premise that we are enslaved to our environment; that the environment (including the social relationships within it) represents one reality, which is up to our minds to discover, accurately interpret, and appropriately respond to – again, prescribing to the stimulus-response paradigm discussed in

Chapter 1. One (albeit minor) aspect of Critical Psychology that acts as a partial antidote to the

Cartesian anxiety is the Hermeneutic tradition, which argues that psychological reality is interpreted within a social and discursive context, and this reality is subject to change (Hesse-

Biber & Leavy, 2011; Parker & Spears, 1996; Orange, 2001). Associated with the Hermeneutic tradition is the field of Phenomenology. Rather than viewing and studying reality and the world as separate from the person, Phenomenology is the study of the world (phenomena) and experiences as perceived by a person; rather than the object itself, a phenomenon alludes to the experience and perception of an object (Banchetti-Robino, 2004; Castillo, 1997).

Both Phenomenology and Hermeneutics were founded on the notion that we are active agents of our environment. This is clearly seen when we examine the concept of affordance, which makes the ontological argument that we can only know the experiences of objects; the objects themselves cannot be known (Castillo, 1997; Gibson, 1979). Gibson‘s (1977) concept of affordance offers an alternative, interactionist view of perception which also changes the way we can think about social interactions. While mainstream perceptual theory states that objects are

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perceived in terms of their physical size, shape, and other ―surface properties‖ (p. 128), Gibson argues that objects are first assessed in light of their possibilities for action, or affordances. We are able to automatically gauge the utility of objects based on how they are designed in relation to our bodies and material world. To Gibson (1977), ―an affordance cuts across the dichotomy of subjective-objective and helps us to understand its inadequacy‖ and that ―it is both physical and psychical, yet neither‖ (p. 129). What Gibson meant by this is that perception does not precede action, but is co-created with action. The Cartesian view, however, is that we first sense an object‘s physical properties so our minds can organize them using the schemas we already have, and then we respond appropriately. On the other hand, Gibson‘s theory of affordance transcends psychophysical dualism as objects in our environment are perceived as relational to us, rather than separate from us. The theory of affordance also highlights that our body, rather than our mind, is the primary site of our experiences, thereby decentralizing the role of the mind in our everyday experiences.

To Russon (2003), the experience of emancipation first begins with our ability to manipulate objects in our environment. The realization that ordinary objects (such as a chair or a plant) offer little to no resistance (other than the physical energy required to manipulate that object), is our first encounter with the notion of ―I can‖ as we become conscious of our physical environments. Therefore we innately feel that objects in our environment are susceptible to our control. However, as we grow older and encounter resistant objects (i.e., other individuals) – first within our family environment and then outside the family environment – we are faced with resistance to exercise control of our interpersonal environment and must develop habits that will instead reinforce the notion of ―I can‖ that was originally developed with inanimate objects (p.

51-52). Therefore, parallel with Gibsonian theory, just as perception cannot exist in isolation but

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is co-created with action, emancipation is afforded through our relationships, as it is, in its subjective or phenomenological sense, something that must be negotiated in our social environment. Therefore, experiencing freedom and empowerment occurs when we learn that we need to develop habits that support our roles as choosers. Unfortunately, the clinician-patient interactions that can often occur in healthcare – including mental healthcare – adhere to the

Cartesian model that underpins traditional North American representationalist theories of perception, where ―the self‖ is not socially contextualized and where intentionality and agency, therefore, cannot logically exist (Coughlan, 2003).

To understand how critical psychology can be used in mental healthcare, it helps to compare it to the current biopsychosocial paradigm (see Figure 1). As we saw in Chapters 1 to 3, modern mental healthcare is based on the theory that we can reduce human personality and consciousness to biological and cognitive mechanisms. This leaves little room to challenge the economic, political, and cultural ideologies that cause human injustice and suffering. This linear and reductionist view of the individual can often cloud clinicians‘ perceptions of normality and abnormality, which can, in turn, impact their treatment protocols. We also saw that mental healthcare is grounded in the North American ideal of the working or functional individual; therefore, the goals that many clinicians set for their patients and clients can inadvertently impose the worldviews and values of white, middle to upper class societies upon all patients regardless of tradition or ethnicity (Maracek & Hare-Mustin, 2009). Much of mainstream social psychology also operates through this stimulus-response paradigm as it views the individual as a passive responder to his or her social and cultural environment. As illustrated in Figure 1, rather than viewing the social and cultural domains together, critical psychologists attempt to understand how culture is shaped by, and in turn also shapes a given society‘s political and

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Figure 1. How Critical Psychology bridges the gap between the economic, political, and cultural trajectory and our social world. The highlighted area denotes the vantage point of the current study. economic environment. As Teo (2009) argues, ―it is insufficient to conceptualize the socio- historical reality as a stimulus environment to which one reacts‖ (p. 40). In other words, culture is not only an aggregate of social norms, customs, and historical events, but also the philosophical lenses through which individuals navigate their environments. Critical psychologists understand these cultural lenses as shaped by ideology, or the concepts that serve the interests of money and power (Teo, 2009). If we were to take a mainstream psychological stance, for example, we would contend that a person‘s ‗behaviour is not adaptive‘. With a critical stance, however, we would argue that ‗this person is alienated‘ (Teo, 2009, p. 42). Therefore the theoretical choice that we make will inform the consequences for the individual; by choosing to believe that a behaviour is not adaptive (as the Cartesian line of thought dictates), the onus of change resides on the individual. This effectively acquits political institutions of any

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responsibility of injustice. Therefore, the concept of the ―individual‖ is not necessarily a natural one, but an ideological one; one that can ultimately disempower the individual.

Since much of mainstream psychology is ideologically driven, one goal of critical psychology is to inform the process of de-ideologization through emancipatory scientific inquiry.

According to Habermas, this calls for the use of Marxist social theory which encourages the oppressed to become more aware of both how they are exploited, as well as the methods by which they can promote social change (Sloan, 2009). Therefore, rather than imposing dominant belief systems on people and treating them as objects that can be manipulated to serve economic interests, or merely interpreting people‘s lives out of sheer curiosity, critical psychologists call for the conscious participation of people in expressing their needs and taking action to fulfill them (Sloan, 2009). This calls for Marx‘s notion of praxis (Bernstein, 1983). In other words,

―intellectual reflection should not be about interpreting the world so much as changing it‖ by challenging the fundamental (often economic and political) foundations that drive inequality

(Sloan, 2009, p. 48).

These views of praxis were shared by other critical thinkers such as Horkheimer, Hegel,

Heideggar, Nietzsche and Foucault, who collectively argued against the dualisms of ‗value and research‘, ‗knowledge and action‘, and ‗individual and society‘ (Sloan, 2009, p. 49). Horkheimer specifically argued that unless knowledge is guided by an ethical-political stance which seeks to fulfil the needs of a whole community and curb social injustice, researchers are merely

‗theorizing for the sake of theorizing‘ and conducting ‗research for the sake of research‘, thereby engaging in indulgent practices that not only reinforce, by also widen the gap between the elites and the rest of society (Bullock & Limbert, 2009; Sloan, 2009, p. 50).

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The issue that was introduced at the end of Chapter 3 was that despite the torrent of research and criticisms that have recast modern mental healthcare as a pseudoscientific agent of social control, none of the critics (e.g., Applbaum, 2006; Greenberg, 2013, Healey, 2006;

Watters, 2010) provided recommendations on where mental healthcare should go from here

(Harrist & Richardson, 2014). Kleinman and van der Geest (2009) suggested that we need to redefine ethics and morality in ways that reflect continental philosophical definitions of ‗care‘

(such as those postulated by Heideggar). Others have more recently suggested that theoretical psychologists resurrect the dialectical method (Harrist & Richardson, 2014). This will help psychologists reconceptualise mental healthcare by shedding light on the specific errors and inequalities that it affords in a given population. The following two sections will discuss these two alternatives.

Reconceptualising „care‟. Kleinman and van der Geest (2009) argue that healthcare that operates within the confines of the biomedical paradigm has separated itself from the moral and existential value of care. The definition of ‗care‘ is broad and multifaceted, however it has two basic elements. The first is technical or practical care, such as feeding children, providing education and helping the sick and the elderly; it is complementary in that ―one person completes another one‖ (p. 159). The second is emotional care, which is when a person shows empathy, compassion, concern, dedication and attachment. In modern healthcare, as Coughlan (2006) argues, the term care can become overly mechanical owing to the medical industry‘s ―love affair‖ with technological innovation (including increased pharmaceutical research) within a culture that is victim to economic and political advertising and consumerism (p. 334). We are socialized to seek novelty and innovation, and modern mental healthcare is not immune to these cultural values as it calls for the research and promotion of new lines of psychopharmacological

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treatment and therapeutic modalities for newly ‗discovered‘ mental disorders (e.g., Greenberg,

2014; Huhn et al., 2014; Hunsley, Elliot, & Therrien, 2014; Wampold & Brown, 2005). To understand, critically, how care is expressed at the doctor-patient level, we need to view it in light of the economic, political and cultural trajectory discussed earlier, which requires us to compare its more philosophical conceptualizations.

Ironically, despite being a Nazi, Heidegger (1962) felt that ethical care (sorge) is a structure of being and that caring (sorgen) acts to serve two aspects of being (in Kleinman and van der Geest, 2009). The first is to orient ourselves towards others (as opposed to the Cartesian or individualistic notion of orienting ourselves inwardly) as dealing with other people will always invariably involve some degree of emotional or practical care. The very purpose of

‗being‘ with others is to care for others and be cared for in return. The second aspect of being is to orient ourselves towards the future; to project ourselves and anticipate our purpose (sich vorweg schon sein) as we move forward in our environment. In this way, care is viewed as intentional, as every action involves, in some way, caring for ourselves or caring for others. This

‗care-fulness‘ is, according to Heideggar, the essence and structure of being a human.

Tronto (1993) took Heidegger‘s philosophy further by moving away from experience of agency and intentionality of caregiving and receiving to ethical medical practice that helps foster them. Her notion of care echoes the core elements of ethical care: attentiveness, responsibility, competence, and responsiveness. She argues, ―for a society to be judged as a morally admirable society‖, it must ―adequately provide for care of its members and its territory‖ (in Kleinman and van der Geest, 2009, p. 160). In other words, it is not enough for care to be a moral quality; it must also be transformed to a political reality. Here, we can see the notion of praxis coming into play; moving beyond the philosophy of care and putting it to practice requires an understanding

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of the political and economic climate in which care is provided. One model that critical psychologists can use to evaluate the level of care in a given system and inform systemic change is the dialectic model, discussed below.

Dialectic method. Broadly defined, dialectics is an approach to understanding the world as an interconnected whole in which opposing forces lead to conflicts, which then lead to both minor and major systemic changes (Sherman, 1976). The dialectic method was first proposed by

Heraclitus in pre-Socratic Greece, and – although preceding Descartes – acts as a powerful alternative to Cartesian thought. As we saw earlier in this chapter, Descartes‘ notion of objectivity is seen as the unification of points of view that will always be true regardless of space

(e.g., geographical space) or time (Danziger, 1997; Descartes, 1989; Sedlaceck, 2011).

Heraclitus‘ dialectical model, however, postulates that time changes everything; that everything in the world is in constant flux (Sherman, 1976).

Hegel used Heraclitus‘ theory to formulate a comprehensive model to understand the process of change (Sherman, 1976). In Hegelian philosophy, the universe is made up of ideal concepts which can only be understood in light of their contradictions. For example, if we are given a stable system or ideology, over time, this stable system (thesis) starts breaking down or experiencing disorder (i.e., the process of entropy) in the form of paradoxes, glitches, criticisms and inequalities (R. Coughlan, personal communication, March, 2014 ). Eventually, these counterarguments and contradictions (or the error of the system) solidify and collectively negate the original system (antithesis). The tension between these two systems, once resolved, becomes a new stable system (synthesis), which again, over time, goes through the same process. In short, dialectics is a method of understanding and resolving the conflicts that are inherent within a certain system and can be used to understand systemic change from the micro (individual and

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Figure 2. Model of dialectical change (adapted from R. Coughlan, personal

communication, March 2014). social) to macro (political and global) levels. Figure 2 illustrate Hegel‘s thesis-antithesis- synthesis model of dialectical change.

While the actual process of dialectical change has been described similarly by its adherents, the driving force of dialectic change has been debated. To Hegel, societies (and therefore societal changes) are driven by the idea of perfection or ―a shadow reflection of a better world somewhere in the cloud of ideas‖, which echoes the positivism, or ‗out there‘ notion seen in natural scientific inquiry (Sedlaceck, 2011, p. 51). His theory that the ‗perfect idea‘ drives antithesis was largely influenced by Christianity and Plato‘s idea of the ‗perfect state‘ and thus belongs to the transcendental realm of philosophy. This endorses a class-based system in which the proletarian (working) class must orient themselves towards the ideas and visions of the leaders and philosophers who convey the ‗cosmic‘ order to the community (Sedlaceck, 2011).

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(entropy)

The word ‗elite‘ itself comes from ‗eligo‘, which means ‗released‘ (Sedlaceck, 2011). To

Plato, one is released to higher status when they prove that they have no attachment to material possessions or family; Platonic thought essentially endorses asceticism (much like Christianity), and positive social change – in a Platonic sense – is when the proletariat conforms to the upper class‘ ideologies (Sedlaceck, 2011). In Hegelian philosophy, the driver of positive social change is this idea of perfection, which is essentially the vision of the elites in a given society. Arguably, this vision closely resembles the dystopias in Huxley‘s (1932) Brave New World, and Orwell‘s

(1949) 1984, where human agency, feelings, and relations are strongly prohibited and severely punished as they are seen as unproductive. In Sedlaceck‘s (2011) words, these ideologies have given rise to a new, evolved version of the human, Homo economicus, whose only purpose is to maximize utility, production, and efficiency to serve the economic interests of the elites, and hopefully, one day, become one of them.

Karl Marx was the only adherent of the dialectical model who translated it to meaningful economic terms (Sherman, 1976). He accepted Hegel‘s idea, but turned it upside down (or rather, right side up) by arguing that the actual drivers of dialectical change are material practices – i.e., what we actually need to do to survive in certain historical, geographical, and cultural times.

Marxists feel that Hegel‘s dialectic method is far too idealistic since it deals with a disembodied set of ideas, and proposes that the world must conform to these ideas to influence positive social change. This very closely parallels the natural scientific method of inquiry, in which theories are arbitrarily devised by researchers and the data collected either confirms (conforms to) their ideas or they don‘t. However, Marxists turn the dialectical model on its head to argue that our scientific concepts must tell us what is actually happening in the real world; in other words, rather than making the world conform to our ideas of perfection, our ideas or concepts need to

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mirror what is actually happening in the real world before we can take steps to augment it

(Sherman, 1976). In short, while Hegel argued that our ideas change the world, Marx argued that the world changes our ideas. Another difference between Hegel‘s and Marx‘s dialectics is that

Hegel‘s version is viewed as a whole, complete, closed system, whereas Marx‘s is a less dogmatic and more flexible tool for analysis. It offers a lens through which we can view the actual problems of everyday science and politics. While Hegel argues that there is one perfect state ‗out there‘ that society is progressing towards, Marx argues that what is considered ideal will always change (e.g., that all systems will either be deviating away from or returning to communism).

Both models can serve as tools for scientific inquiry; Hegel‘s dialectics parallels the hypothetico-deductive scientific method, which is theoretically (ideologically) driven and therefore relies on a top-down primarily quantitative approach to analysis, while Marx‘s dialectics is materialistic and parallels the inductive or bottom-up method which is more data- driven. Therefore, in order to develop concepts or ideas that will have meaningful social impact in a given society, we need to view Marx‘s dialectics as an important component of our research or inquiry. The first step is to abandon the idea that our research should be driven by a theory, or pre-defined set of ideas or hypotheses. This calls for the use of qualitative methods, which are more inductive and data-driven.

Purpose

Prior research identified several factors that suggest mental health service delivery in Kuwait is quite poor, however several questions still remain to be answered (see Current Mental Health

System in Kuwait in Chapter IV). Therefore, the purpose of the current project was to address these questions in depth using qualitative methods with a critical psychological (and dialectical)

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lens by understanding the policies that either directly or indirectly endorse unethical caregiving practices in Kuwait; how individuals in Kuwait experience care – i.e., by studying the phenomenology of care-giving and receiving; what individuals‘ experiences and narratives tell us about the disparities between mental health theory and practice (i.e., what are the errors of the current system); with the goal of informing policy initiatives that will help correct the errors and favour more caring and ethical service delivery.

These goals were addressed by answering more specific questions such as 1) what are the clinical, cultural, and political facilitators and barriers to providing mental health care in Kuwait?

2) What are the disparities in how mental health professionals and mental health service users discuss their perceptions of mental health and experiences delivering or receiving care, and what does this tell us about the distribution of power within the mental health sector? 3) How can current policies and practice be modified to design a more culturally nuanced approach to mental healthcare in Kuwait? And, in theoretical terms, 4) what is the extent of the mental health problem in Kuwait and in what ways can anti-stigma campaigns effect individuals‘ perceptions of mental health, illness, and help-seeking behaviour, and who does this benefit? The remainder of this chapter will outline the theoretical and procedural techniques used to answer these questions.

Data Collection

After receiving Trent University Research Ethics Approval, participants were recruited through personal contacts and a snowball sampling technique. This means that I contacted several potential participants and asked if they would like to participate in the study; those who agreed to participate connected me with other individuals who were interested in participating (Hesse-

Biber & Leavy, 2011; Noy, 2008). I recruited mental health professionals (psychiatrists,

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psychologists, social workers, counsellors and family practitioners who provided therapy), mental health service utilizers (individuals who have accessed or are currently accessed mental health services in Kuwait) and members of the general Kuwaiti community (individuals with no prior experience delivering or receiving mental healthcare).

Given my previous work and networking experience in Kuwait, I had already established connections within the mental health sector. I first recruited mental health professionals from a private mental health clinic, and asked for permission to distribute recruitment posters for mental health service users. Owing to ethical considerations, I could not use snowball sampling to recruit service users as it would call for practitioners to breach confidentiality. In the event that service users wanted to participate, they contacted me through the information provided on the recruitment posters (i.e., by phone or email). My initial contacts also connected me to mental health professionals at four other mental health centers in Kuwait, three of which granted permission to leave recruitment posters for patients and clients in their waiting rooms. Other professionals worked in private practices or hospitals and were recruited through snowball sampling. Members of the general Kuwaiti community were also recruited through personal contacts and snowball sampling. Participants were recruited until themes reached a point of saturation – i.e., until the patterns in people‘s narratives became consistent and no new knowledge was being gained (Straus & Corbin, 1998).

The purpose of sampling from three different populations was to gauge the perceptions and experiences of mental health and illness from different vantage points to analyze any discrepancies between the three groups and also because interviewing only those who have direct experience with the mental health sector would exclude the perceptions of a large population of

Kuwait who may not agree with the notion of mental healthcare (Scull et al., 2014). It would also

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assume that the perceptions of individuals who don‘t utilize mental healthcare (or actively resist it) are invalid. Therefore, triangulating data from three different populations afforded a more democratic approach to analysis. Additionally, this study is a continuation of a previous study by

Scull et al (2014), which alluded to the lack of mental health infrastructure in Kuwait. However, no mental health professionals were recruited in that study, therefore it was necessary to understand how the lack of infrastructure not only affects service utilization, but also how it impacts service delivery.

Participants. The 26 participants (58% female, 42% male) in this study consisted of 11 mental health professionals, 9 service users, and 6 community members. Among the mental health professionals, 64% were female, while 36% were male, and they ranged in age from 28 to

63 years. There were two family practitioners (M.D) who provided mental health services, two psychiatrists (M.D), four psychologists (Psy.D/PhD), and three counsellors (M.As). All four medical professionals were employed in the public sector (36%), while the psychologists and counsellors were employed privately (64%). In terms of nationality, the majority were Kuwaiti

(36%), while the remaining were North American (27%), other Arabs (18%), or other (18%), including one South Asian therapist and one Arab-American therapist. Most professionals obtained their graduate degrees and training from North America (64%) while only a minority – primarily those employed in the public sector – were trained locally in Kuwait (27%). One professional was trained in South Asia.

Among the 9 service users, 56% were female, 44% were male, and they ranged in age from 18 to 56 years. In terms of nationality, 33% were Kuwaiti, 33% were of other Arab descent,

11% were South Asian, 11% were North American, and 11% were South American. All service users either had a Bachelor‘s degree or were in the middle of obtaining one. Most participants

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lived in Kuwait for most of their lives; only one was in Kuwait for less than ten years. The reasons for seeking therapy were related to eating disorders, substance abuse, dealing with the stigma of being bisexual or homosexual, schizophrenia/psychosis in a family member, parental divorce, dealing with conservative family values, learning disorders, sleep disorders, culture shock, bullying, inhumane treatment from local law enforcement, racial discrimination, depression, anxiety, and/or ‗living a double life‘ in a Muslim country. Majority of the participants sought more than one therapist in both the public and private sectors in Kuwait

(78%), while only 22% saw one therapist only. Most services users were in regular therapy (at least twice a month) for at least 3 months (56%), while the remaining had 3-5 sessions (22%) or a single session with a therapist (22%) on an ‗as needed‘ basis.

Out of the 6 participants who had no experience receiving or delivering mental health care in Kuwait, 50% were male, 50% were female. All but one participant was Kuwaiti; the non-

Kuwaiti participant, however, was both born and raised in Kuwait and lived there for more than

20 years so had a very good understanding of Kuwaiti culture. Participants‘ education backgrounds varied; one was a surgeon, two had backgrounds in physical rehabilitation, one was working as an educator, and two were students. Given that Kuwait subsidizes post-secondary education for Kuwaitis, it was difficult to recruit participants who were at least 18 years of age who did not have (or were pursuing) at least a Bachelor‘s degree. Additionally, given that the study was specifically about mental healthcare in Kuwait, it was difficult to recruit participants who actively resisted the notion of mental healthcare. It was also difficult to conduct interviews with individuals who did not speak English, therefore neither of these two groups are well represented in this study. Findings should be interpreted in light of these caveats.

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Semi-structured interviews. The interviews were conducted in private offices at mental health clinics or participants‘ homes, depending on what was most comfortable for them. One participant chose to be interviewed in a private coffee shop. The interviews were semi- structured, which meant that there were several topics that I aimed to cover within each interview through a series of broad questions and more specific prompts, however the questions did not need to be answered in any specific order. The interviews were also open-ended; this means that participants were asked questions that prompted in-depth discussions (rather than yes or no answers) and it allowed participants to direct the course of the interviews and discuss topics that may not have been in the original interview protocols. Therefore, the interviews resembled in- depth conversations, run by the participants rather than the interviewer. This served two purposes: first, it allowed participants to choose the topics that they felt were most important, thereby giving them more control of the interview. Second, it informed important questions for future interviews that may not have been in the original interview protocols.

There were three separate but overlapping interview protocols for this study (Appendices

D-F). All participants were asked to talk about Kuwait as if they were talking to someone who had no knowledge about the country; this helped me understand participants‘ immediate associations with Kuwait (such as specific cultural, religious , or sociodemographic attributes), and whether or not their perceptions of Kuwait were generally positive or negative. All participants were also asked to define health, mental health, and mental illness (in that order) to understand how these terms are conceptualised and whether there are any intergroup differences

(i.e., between mental health professionals and service users, or Kuwaitis and non-Kuwaitis) in their perceptions. Given that most mental health professionals in Kuwait have been trained abroad, I was also interested in learning about how mental health and illness look different in the

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different countries they have practiced in (i.e., how do personalities, trauma, cultural ideologies and coping look different transnationally?) This allowed me to explore these factors in Kuwait relative to other countries. Mental health professionals were also asked to discuss their educational background, what drew them to Kuwait, as well as more specific questions such as what personal success and failure feel like as a therapist, and the types of issues they see the most with their patients (if they hold medical degrees) or clients (if they do not hold medical degrees).

The interview protocol for service users was designed to understand how they experience mental health and illness, and whether or not they found therapy beneficial in Kuwait. For example, ―what can you tell me about your experiences with mental health care in Kuwait?‖ is a very broad question that allowed participants to talk about aspects of their experience that they felt were most important (e.g., whether it was their experience with mental illness or whether it was the quality of service they received or both). It also indirectly prompts participants to discuss their reasons for seeking therapy instead of having to ask them directly. Other questions were directly evaluative, such as ―in what ways do you feel your therapist’s cultural background shapes your interactions with him/her?‖ or ―has your therapist ever done or said anything to make you uncomfortable?” Since service users are more likely to be honest about poor service delivery than those providing the service, these evaluative questions were pivotal for this study.

Interviews with individuals of the general Kuwaiti community were shorter, and the questions largely revolved around their perceptions of Kuwait, mental health and illness, and whether they would ever seek mental health services if they needed to. Participants in all three groups were finally asked, ―if you had the ultimate power to organize structures and policies for changing mental healthcare in Kuwait, what would they look like?‖ This allowed the interview

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to move to much broader topics and shed light on the types of policies and legislations that participants were aware of, and the types of changes they felt would most benefit Kuwait.

The questions and probes were modified with successive interviews. The interviews ranged in time from 35 minutes to approximately 3 hours, and the average interview was almost

2 hours. All interviews were transcribed verbatim (typed up word for word). In qualitative research, it is important to acknowledge the researcher‘s role in influencing data collection and analysis (Charmaz, 2000; Hesse-Biber & Leavy, 2011; Strauss & Corbin, 1998; Willig, 2008).

Therefore, I kept thorough memos in a journal for the duration of the study, which I referred to consistently to uncover any biases that might have affected the research (see section on

Reflexivity). Not only did these memos include my personal impressions of the interviews, they also listed the themes (patterns) that I began constructing as I conducted more interviews.

Data Analysis

Qualitative researchers generally recommend the use of more than one method of analysis of semi-structured interviews, of which grounded theory, interpretive phenomenology and discourse analysis are the most common (e.g., Starks & Trinidad, 2007). The analysis of my data was divided into two phases; in the first phase, I employed an interpretive phenomenological approach (see Biggerstaff & Thompson, 2008; Parker, 2005; Smith & Osborn,

2008; Starks & Trinidad, 2007). My goal here was to describe the meaning of participants lived experiences and perceptions of mental health and illness. This involved the identification of the descriptions of these phenomena into common patterns or ‗themes‘. This thematic analysis was taken further by clustering themes into discrete categories to describe the ‗essence‘ or ‗core commonalities‘ of participants experiences (Starks & Trinidad, 2007). The second phase involved a critical discourse analysis which was more semiotic in that I focussed on how

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individuals shared their stories and was concerned with the ways in which power and ideology are created, conveyed, and reinforced within institutional settings (the mental health sector, family life, religion, and law, for instance, were all viewed as ‗institutions‘). The goal here was to understand how discourses of power and ideology shape individuals‘ identities, activities, and relationships and the purpose of this analysis was to inform policies and practices that will aim to reduce any power disparities identified in the analysis. The following sections discuss the theories behind and rationales for each approach as well as the specific procedures used.

Phase 1: Interpretive Phenomenological Analysis. All transcripts were initially analyzed using interpretive phenomenological analysis (IPA). IPA was developed by Jonathan

Smith (e.g., Smith, Horré, & Van Langenhove, 1995; Smith & Osborn, 2008), and its theoretical underpinnings stem from Husserl‘s phenomenological perspective of consciousness, with hermeneutics and symbolic interactionism as its pillars. Symbolic interactionism was introduced to sociology by Max Webber and popularized by George Herbert Mead, who contended that the meanings individuals ascribe to events drive their actions; it is these meanings that are the focus of IPA, but they can only be explored through an interpretive process (Biggerstaff & Thompson,

2008; Smith & Osborn, 2008). IPA‘s goal, then, is to understand in depth how respondents make sense of their social world and their place within it through a detailed examination of their stories. This is in sharp contrast to Psychology‘s need to ‗discover‘ the object or event to produce

‗objective‘ statements (Smith & Osborn, 2008). Therefore, IPA places the respondent, rather than the researcher, as the expert or ‗co-researcher‘ in the interrogation process (Parker, 2005).

IPA encourages researchers to play close attention to their own pre-conceived notions since analysis involves a double hermeneutic (i.e., a two-stage process of interpretation). This means that while the respondents tried to make sense of their own world, I attempted to make

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sense of how the respondent was making sense of their world (Smith & Osborn, 2008). IPA is therefore limited in its analytical scope because it must assume a ‗chain of connection‘ between an individual‘s narrative and their thoughts and feelings. This one-to-one correspondence is essentially a positivistic stance, rendering IPA far more descriptive than analytical and theoretically similar to cognitive psychology. Therefore, IPA converges with mainstream psychology owing to its interest in how people think about their world (i.e., it is concerned with mental processes), but diverges from mainstream psychology owing to its focus on deciding how to study it (Smith & Osborn, 2008).

As with all qualitative analysis, there is no single or definitive way to carry out IPA – partly owing to the fact that there are generally no attempts to test an a-priori set of assumptions or hypotheses, but also because research questions can be modified during the data collection and analysis phases of interrogation. Additionally, IPA‘s goal is depth, not generalizability; for this reason (as well as the fact that qualitative methods are time consuming), small sample sizes are preferred (Willig, 2008). This makes IPA, according to Smith and Osborn (2008), less nomothetic (it is not concerned with aggregate data for the purpose of making predictions or probabilistic claims), and more ideographic (in that it also makes specific statements about individuals and events). Therefore, rather than relying on random or representative sampling,

IPA – similar to other qualitative methods used by social anthropologists and ethnographers – relies on purposeful sampling from a particular group of interest. Like an anthropologist, the researcher reports on that culture in detail. When these findings are assessed in light of existing theoretical and empirical literature, the researcher can begin to make theoretical (as opposed to empirical) generalizations (Smith & Osborn, 2008).

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I carried out this analysis by reading one transcript at a time, and highlighted and summarized the most poignant sections of each transcript using concise phrases and as many of the participants‘ words as possible. I then conducted a micro-level thematic analysis which involved documenting themes in each transcript – again, deviating as little as possible from the participants‘ own words. For instance, if a participant said that she was scared her parents would punish her for having an ―inappropriate lifestyle‖ and exhibiting ―immoral behaviour‖ and is thus living a separate life that she keeps hidden from her family, fear of punishment, importance of exhibiting moral behaviour, and living a double life would be some themes that concisely capture her feelings and experiences in this instance. This micro-level analysis was carried out for each transcript.

After conducting this initial analysis, I moved to a higher level thematic analysis by connecting the themes in a meaningful way. For example, if some participants discussed how their therapists‘ prejudices offended them during therapy, and others discussed that their therapists did not listen to them, or breached confidentiality, these themes clustered into under higher order themes such as unethical service delivery or negative personal experiences. Themes were also clustered based on participants‘ demographics. For instance, some themes were more common with physicians than with counsellors, so this became an important part of my analysis.

With IPA, initial themes can also allow us to ask more specific questions (e.g., ―what does it mean to be a Kuwaiti woman?‖) that seek to answer how a participants‘ meaning of their social world influences their actions, and vice versa.

Although IPA can allow us to understand the ways in which some Kuwaitis navigate their world, and how women can be treated differently than men, our analysis cannot go further with

IPA. For instance, unless participants specifically make the connection between patriarchy,

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Sharia law, and double standards for men and women, we cannot draw themes from these very important political and cultural factors. Additionally with IPA, we are listening more to what participants say, and not to what participants do not say and asking why. We can make the argument that IPA is similar to grounded theory (Straus & Corbin, 1998) since both methods restrict our ability to construct themes and draw conclusions that are not explicitly grounded in our participants‘ narratives. Our qualitative analysis therefore becomes limited to a linear method of inquiry. Its attempt to tap into the ‗inside perspective‘ of a respondent‘s meaning system – i.e., the ‗phenomenology‘ aspect of IPA – has led to several criticisms by Parker (2005). First, its tendency to search for intentions, where the researcher believes that what someone says is a true reflection of what they intended to say makes IPA victim to constructivism, or the attempt to illuminate underlying mental processes of the respondent. Therefore, IPA becomes susceptible to naïve realism, where the researcher treats the narrative as empirical truth; this limits our understanding of the political and cultural resources that structure their narratives.

IPA‘s other problem is that of reduction to the individual (or abstraction); when we separate someone‘s narrative from societal forces and focus on the ‗inside‘ perspective, we lose sight of how the ‗inside‘ perspective is dependent on what‘s on the ‗outside‘. Therefore, if there is no direct reference to power or ideology, the researcher assumes that they cannot talk about these factors. This makes us prey to a sort of ‘not our department thinking‘, where we limit our domain of inquiry - just as most traditional academic and political institutions prefer (Parker,

2005). Referring back to Figure 1, we can think of our analysis as ‗trapped‘ in the social – and arguably, cognitive – domain, with limited understanding or explanation of the forces that drive these sociocultural nuances. This makes our qualitative analysis resemble much of the mainstream research in psychology, since, if performed alone, IPA has limited emancipatory

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potential. Therefore, an additional level of analysis was needed to understand how the participants‘ lived experiences, and perceptions of them , can be contextualized within Kuwait‘s economic, political and cultural environment. This called for a Critical Discourse Analysis.

Phase 2: Critical Discourse Analysis. By the 1970s and 1980s, as anti-psychiatry movements were well underway and feminist scholars published criticisms of mainstream psychology (e.g., Harraway, 1988), social psychologists argued for a ‗new paradigm‘ in psychology to ―treat people as if they were human beings‖ (Parker, 2005, p. 88). They began their development of a new methodology by focussing on humans‘ single most defining characteristic: the ability to speak. This caused social and developmental psychologists to turn to language to understand the social rules and roles of any given social world – from classrooms to large industrial complexes (such as pharmaceutical giants and the porn industry). A discourse analysis, therefore, is not the same as the prototypical thematic analysis which rarely goes beyond grouping themes and quotes together to summarize common perceptions and experiences in a set of interviews.

As we saw in the previous chapter, Kuwait – despite having a very collectivistic culture characterized by high levels of solidarity – is highly segregated. Discourse analysis becomes a very powerful tool in a society such as Kuwait because it is capable of shedding light on the type of language used to create and reinforce demeaning and dehumanizing images of people who are made to rank low on various hierarchical orderings of society, such as socioeconomic class, race, gender, and even nationality. Additionally, it allows us to see how these images bleed into the negotiations of mental health and illness in mental health settings (see Chapter III for a discussion on illness negotiation). It also encourages us to understand how the relationships between people – or the social bonds – formed in this context convince individuals that the world

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naturally – and perhaps also should – operate in this way (Parker, 2005). In this light, discourse analysis – specifically, a critical discourse analysis – is the study of how language is organized in various social bonds to create and reinforce disparities in power. It picks up ideas from Marx and Foucault and involves the reading and re-reading of texts to study how everyday language influences our own narratives in such a way that can convinces us (including the researcher) of the legitimacy of these disparities (Parker, 2005; Willig, 2008).

By using a critical discourse analysis, I was able to transform the Phase 1 thematic analysis from being descriptive (and explanatory only within the confines of what participants said, or the connections I made based on demographic factors), to functional, analytical, and explanatory in a more critical sense. I did this by exploring common themes from my Phase 1 analysis (e.g., fear of punishment) in light of Kuwait‘s political climate which I understood using both existing literature (see Chapter 4) as well as my interviewees‘ own insights. If we refer to

Figure 1 again, we can see this process as releasing their narratives from the mainstream (e.g., biopsychosocial) paradigm, and putting them on the economic, political and cultural map. Parker

(2005) referred to this process as the articulation of chains of meaning that can be independent of the speakers. In some instances, participants made these connections; in others, I navigated

(interacted with) several different transcripts at once to draw connections. For instance, if some participants discussed racism, while others discussed human rights violations, we can link these two themes together by arguing that race (given that south-east Asians, Indians and Africans are most vulnerable to human rights violations) is one of the many factors that separate elites from the lower class even though this was not explicitly said in the interviews.

Using a Foucauldian approach, I looked at how discourses facilitate or limit, and enable or constrain the power individuals had to say something; i.e., I looked at what was said, by

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whom, when, where, and how. For instance, if a participant made a disclaimer such as ―I have nothing against the labour class and all those people, but they need the most mental help‖, she is implicitly making the statement that ‗I am separate from this group‘. Here, we can see how knowledge, power even identity are reproduced through language alone; the very use of political and social discourses such as ‗labour class‘ and ‗those people‘ immediately forces the speaker to position themselves as an outside member of this group – a group whose members are vulnerable, in need of ‗mental help‘ (i.e., it is the responsibility of the individual to produce positive change in their lives) and thus have less power. By distinguishing ‗those people‘ from

‗us‘, we are adopting a discourse that demeans and dehumanizes members of other groups by buying into the ‗us versus them‘ dualism inherent in any class-based society. The sheer fact that virtually all members of the labour class are from third-world countries also effectively prompts the ranking of individuals based on characteristics such race, ethnicity and nationality. This then opens the door to further critical questions such as ―is Kuwait‘s population really experiencing a mental health problem, or is it a societal one?‖ and ―how much power does the mental health sector have to make positive social changes in Kuwait?‖

Conducting a critical discourse analysis allowed me to form meaningful connections by understanding how language conveyed symbols or images of power and ideology with the goal of opening doors to challenge and resist these images. Language was therefore used as a primary tool to understand how different types of language position some individuals as elites and others as the oppressed – as shown in the example above. This allowed me to construct broader, more politically oriented metathemes which explain the material conditions that structure, regulate, and administer institutional practices within which language is generated and social bonds

(including familial, professional and therapeutic relationships) are built in Kuwait. Therefore,

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while IPA deals with phenomenology, critical discourse analysis deals with praxis – both in terms of how psychology is practiced in a given society and its capacity to influence positive social change, as well as in terms of informing more constructive, and data-driven healthcare policies and practices.

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Chapter VI. Results: Discourses on Oppression, Inequality, and Resistance in Kuwait

This section is divided into two components: the first draws on the twenty six participants‘ overall impressions of Kuwait for the purpose of contextualizing the second component, where I report on the themes and metathemes constructed from their narratives. All the themes were collapsed into four broader metathemes, and each theme uses poignant quotes to support them.

The themes and metathemes are explanatory, rather than descriptive in nature; in other words, they were constructed for the purpose of explaining a given phenomenon. Since participants‘ names were removed, pseudonyms (e.g., Participant 3, or P-3) are used with the reference numbers beside them (e.g., P-3: 25-38) to refer to the lines in the transcript where the quote can be found. I also mention the participant‘s nationality, gender, or profession when it is relevant to the quote or theme (e.g., P-10: Male psychiatrist, 320-325, or P-18: Female Kuwaiti service user,

1215-1220). It is also important to note that many of the narratives are about (and taken from) a clinical population and those who regularly interact with clinical populations. Therefore many of the perceptions about Kuwait‘s social, cultural, political and economic environments are negative in that they emphasize the more problematic aspects of living in Kuwait, or being a

Kuwaiti.

Perceptions about Kuwait

The interviews, as a whole, contained a wide spectrum of perceptions about Kuwait ranging from extremely positive to extremely negative, regardless of participant demographics, including gender and nationality. Every participant I interviewed felt that Kuwait is a highly collectivistic, family oriented and honour-based society. Several participants also felt that most

Kuwaitis are very ―tribal‖ in that members of a certain tribe, class, or family name will always support members of their tribe in times of need (e.g., P-1: 139; P-11: 83-84) and that an

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individual‘s as well their family‘s reputation are extremely important (e.g., P-6: 821-823). Most participants, including Kuwaitis, also felt that Kuwaitis are generally extremely wealthy, which usually results in having more ―materialistic‖ attitudes (P-21: 159-160) or a ―sense of entitlement‖ (P-3: 499). Most of the women I interviewed strongly stated that Kuwait is also a highly ―sexist society‖ (e.g., P-21: 159), and much of the patriarchal structure of the society is owing to the misuse of Islamic texts (e.g., P-22: 692-693). However, some felt that Islam has more positive than negative impacts in Kuwait. A young Kuwaiti male, for example, felt that

Kuwait is highly humanitarian and charitable because of Islamic teachings:

There are some values that I like. Most of these values are religious beliefs. So

when it comes to Kuwaitis, they are very well known [in terms of their] humanity

and charity… The sense of charity is really high in Kuwait…Like even if the

person made a huge mistake in his life, the charity is… Like in Christianity, you

go to be the church and then you confess. In Islam it‘s more action-based. You

did a bad thing, you want to replace it with a good thing (P-17: 394-398; 418-

421).

Although, there was also a strong perception – primarily among Kuwaiti and other Arab women – that religiosity, tradition, and collectivism are façades:

They are sitting and gathering all the time. Families – big families. But everyone

is hiding their actual emotions. They are hiding their thoughts. They are just

laughing and sharing food but they are not honest in their feelings here… But in

front of the doctors and therapist, they will tell you the details about their faith,

about their spirituality, and you‘ll find nothing. They‘re empty. (P-14: 553-555;

984-986)

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Similarly, Participant 1 felt that there is no ―genuineness about people, the way they carry themselves and the way they live their lives‖; this ―makes it very hard to find genuine natural people and not think twice‖ about interacting with them (P-1: 167-171). Most participants – including Arabs – also referred to Kuwait as a culture of ―denial‖ (e.g., P-1: 688-695; P-7: 615-

624; 889-891; P-9: 258-260; P-11: 710-712; P-13: 773-776; P-16: 135-147). According to these participants, much of this denial pertains to subjects that are taboo, ‗haram‘ [sinful], or merely considered ‗deviant‘ and therefore uncomfortable to talk about, such as the pervasive sexual violence, rampant drug use, homosexuality, or suffering from mental disorders. ―In Western cultures, we tend to bulldoze right over denial and not allow it in the interest of what we think is the right thing to do‖; however, in Kuwait, ―there is a cultural denial‖ (P-7: 890) for everything that is taboo ―because everybody is in denial‖ about these topics (P-7: 1015-1016) if they negatively affect their reputation or family‘s honour. Some felt that in the interest of reinforcing the perception that Kuwait is very collectivistic and family oriented, individuals will deny that many families are often highly ―dysfunctional‖ or emotionally ―disconnected‖; that the social cohesiveness is merely a ―frame‖ that families project to other people to hide the fact that there is actually a lack of bonding between family members (P-14: 516-528).

Several participants attributed Kuwait‘s cultural paradoxes to the effects of Saddam

Hussein‘s invasion of Kuwait in 1990. Two local women I interviewed anthropomorphized

Kuwait during their interviews as they reflected on its aftermath. One described Kuwait in the feminine; as someone who was betrayed and raped by her ―brothers‖, causing her to lose her

―glory‖, ―honesty‖, ―love‖ and ―spirituality‖ (P-14: 742-747). The other attributed this loss to the widespread trauma that resulted in extreme black-and-white thinking (P-4: 742-743). Not only did these descriptions humanize and feminize Kuwait, it shed light on feelings of honor, betrayal,

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and the search for power and control that are deeply embedded among many of its people.

Today, Kuwaiti society is equally raw, expressive, and liberated as it is unpredictable, enigmatic and rigid in its values. A clinical psychologist, who specializes in complex trauma, explained this paradox:

When people are traumatized, they go back to what they know, or they go to the

extreme opposite. When you look at a country like Kuwait, people go ―what we

grew up with and how we live hasn‘t kept us safe because the invasion

happened… So what we‘re going to do is we‘re just going to go to this extremely

and be really liberal and just forget about everything we learned‖… And then

you‘re on the other end of the spectrum, just really adhering to what they grew up

with and take it to the extreme… Really extremely conservative…They just start

thinking in very black and white terms and that screams trauma. (P-4: 293-315)

A male participant also reflected on Kuwait‘s conservatism after the war; that people had more ―respect‖ and ―long before the invasion, they had alcohol‖ and women ―did not cover themselves‖ (P-18: 738-739). Some people who remained in Kuwait during the invasion also described how Kuwait was socially cohesive and egalitarian before the invasion but individualistic and materialistic after the invasion. The following quote is by a Kuwaiti woman who remained in Kuwait and reflected on her personal experiences and perceptions about these changes:

We were very afraid all the time, afraid of being attacked by Iraqi soldiers. The

good thing is that we loved each other, and on the gathering we were caring about

each other, and we were in a big house, all my cousins and grandmothers and

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grandfathers, we loved each other. There was no infidelity or no hate or envy, just

we were taking care of each other, all together, we wanted to protect each other.

This thing, we lost it now… Now everyone wants to be better than the other one.

Everyone wants to prove that he is better than you. Better in raising their kids,

having better clothes, having a good job, having a good husband, everything.

Travelling. In every minute thing you could ever expect. But before the invasion

we didn‘t care about all these things. We didn‘t care about what we are wearing…

Now all they do is talk about these things (P-14: 749-752).

A young Kuwaiti woman also felt that Kuwait is now ―largely driven by images‖ (P-21:

159-162). Many interviews, however, suggest that the United States‘ liberation of Kuwait, which brought on rapid modernization, may be the driving factor behind these sociological and cultural changes (see Metatheme 2). Another Kuwaiti woman, for example, described the paradox that

―Kuwait is like a third world country, but with money‖ (P-11: 194) which echoes what most other participants said. Money and power were often discussed together during the interviews, which brings us to the next topic: nepotism.

Many individuals (Kuwaitis included) felt that its economic environment promotes

―shady‖ (P-11: 66) practices among professionals; one said that Kuwait‘s mental health sector reminds him of the ―wild west of mental health practice‖, where ―anything goes‖ and ―lots of weird stuff happens‖ (P-3: 202-205). A Kuwaiti physician gave a personal account of ―breaking rules and cheating‖, and also highlighted the perception that the west is more ethical:

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I am one of those people. I will cheat and lie. So my value system, my ethics, are

a little bit shady. Not because I don‘t think twice about it. I had to think twice

about it when I went to the West. And met Western people, and started seeing

how their ethics are – they‘re very ethical people. But here, it‘s the general

population, it‘s normal to cheat. (P-11: 65-68)

One of the most unique cultural and political factors of Kuwait that‘s associated with

―cheating‖ was the Arabic term, ‗wasta‘. Wasta loosely translates to ‗nepotism‘ or ‗clout‘. In other words, ―being Kuwaiti allows for a certain amount of security and risk-taking‖ (P2: 250; P-

3: 486-488; P-4: 48-482; P-11: 678-679; P-13: 312). For instance, ―you could drive fast and hit a car, but [if you get into trouble] your tribe will support you‖; therefore, ―rather than worrying about the laws of the country like you would in North America‖, individuals can use their

‗wasta‘ to get out of trouble (P-11: 83-86). In some cases, people can use wasta to change the cause of death in a death-certificate (P-2: 250) or make patient files ―just like that, poof!

Disappear into thin air‖ (P-11: 676). This is particularly common with medical and forensic cases related to suicide and drug or alcohol overdoses, all of which are illegal and stigmatizing in

Kuwait (P-2: 244-250). Those who have wasta in Kuwait either belong to, or are associated with, an ‗elite‘ group; it is essentially a get out of jail free card, because ―your tribe will support you‖ no matter what you do (P-11: 84). This is true for many individuals who have ‗connections‘ or have a high enough income that they can bribe someone to make things ‗disappear‘, including people (e.g., P-26: 344).

The goal of the previous paragraphs was to set the stage for the main section of this chapter, where I describe the themes and metathemes that I constructed based on the interviews.

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Kuwaiti culture, despite having the reputation of religiosity, collectivism and humanitarianism, was also described as being materialistic and patriarchal. One of the best ways to understand

Kuwait – specifically, to understand what mental health and illness means in Kuwait – is to compare it to the Western world. This involves looking more specifically at the cultural, political, and economic factors that make them similar and set them apart. These factors were all discussed in the interviews, therefore the goal of the next section is to contextualize the main findings within narratives that describe these dynamics in Kuwait.

One of the main questions I wanted to answer was how mental health and illness are different compared to the West. This is addressed under Metatheme 1. Metatheme 2 was constructed as an adjunct to Metatheme 1, since it answers the broader political and societal questions on why mental illness occurs in Kuwait. The purpose of Metatheme 3 is to address how ideological and cultural conflicts between ‗Western‘ and ‗Kuwaiti‘ value systems impact mental health and mental health service delivery in Kuwait, with a special emphasis on the impact of global (i.e., American) medical discourse on indigenous Arab meaning systems.

Finally, Metatheme 4 explains what resistance to oppression looks like in Kuwait, particularly among service users and other ‗vulnerable‘ populations; it also sheds light on the narratives that describe how Kuwait is currently experiencing a strong undercurrent of social reform.

1. Mental health issues are presented and need to be treated differently in Kuwait as compared to how they are in the West

This metatheme primarily draws on the insights of the mental health professionals I interviewed, but also includes many service users‘ narratives. Here, I explore the ways in which mental health issues look different in Kuwait than they do in the West. Since most clinicians also practiced outside Kuwait, many of them found vast differences in how mental illness is presented cross-

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culturally. One of the most prominent themes was related to family. Since family is the most integral component of an individual‘s life in Kuwait, familial conflicts were more likely to land an individual in therapy than any other social or psychological issue (1.1). Another point that was mentioned in several interviews was that individuals in Kuwait are more likely to present emotional distress somatically (1.2). Therefore, I also interviewed clinicians in physical rehabilitation (e.g., physiotherapy) and family medicine. They also felt that psychosomatic issues are rampant in Kuwait. Finally, many individuals felt that mental health issues in Kuwait are more severe than they are in the West, for several different reasons (1.3).

1.1. Family members are more integral to the therapeutic process in Kuwait as compared to the West.

All of the eleven mental health professionals I interviewed felt that most mental health issues stem from problematic family dynamics. While this is also true in the West, it seems to be more prominent in Kuwait since relationships are more ―intensified‖ (P-3: 385-389). One therapist felt that her clients in North America had more ―individualistic‖ issues related to personal growth, however in Kuwait there are ―a lot more relationship problems‖ that are driven by ―dysfunctional families‖: ―family issues tend to be on the table for every client I‘ve had here in Kuwait‖ since people ―define themselves by their relationships here‖, more so than they do in

North America (P-1: 612-619). Issues generally revolved around parents or husbands or partners being too authoritarian, or not being able to live up to an authority figure‘s expectations. Many young adults, therefore, feel ―torn‖ between helping themselves and ―rocking the family boat‖ or suffering in silence (P-4:1047-1049). Some clinicians felt that ―you have to work with the family through the individual‖ (P-3: 359-360), because when you‘re ‗treating‘ an individual, you are

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treating their family (P-4: 689-692). Many times, family members do not understand how to respect the boundaries of the client:

Some people don‘t always respect the boundaries of their family members, or

even of their friends… Sometimes their intention is caring… But sometimes their

impact is a little bit more negative… Sometimes they overstep boundaries [and]

interfere with therapy; sometimes they try to influence the therapist‘s opinion

[and] think they know what‘s best for the client as opposed to the client

themselves [and can] disempower the client or they emasculate the client or they

don‘t operate on… Principles that create equality between men and women. (P-4:

1679-1698)

This overstepping of boundaries can go further because many family members will try to

―extract information‖ from a therapist (P-4: 1704-1706) and are known to ―trash therapists‖ if they don‘t give them the information they‘re looking for, and accuse them of not caring about their client (P-4: 689-1703). ―You try to illuminate them, but it (usually) falls on deaf ears‖

(1703-1704). Therefore, many therapists are easily swept away by family dynamics; Participant

4 felt that therapists in Kuwait need to learn to be okay with ―pissing a lot of people off‖ (P-4:

1715-1726). One felt that some parents can be overly ―clingy‖: in many cases, ―the mom is making all the appointments for the 25 year old… And [she] wants to know everything‖. Not only does this interfere in the therapist‘s process, ―you can bet they‘re interfering in the child‘s process… or the adult client‘s process‖ (P-9: 967-970). The reverse also seems to be true for younger clients who are raised by ―hired help‖ rather than their parents; in these cases, parents are generally less involved, and feel that therapy should be a ―quick fix‖ (P-6: 205-224).

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Several clinicians felt that therapy feels more interpersonal in Kuwait than it does in the

West since relationships are so important, therefore interpersonal therapy seems to work best for most clients (P-3: 477-468). This also means that ‗transference‘ is more common because of this interpersonal emphasis. Two clinicians felt that they are viewed as authority figures, since most clients ―want you to be the expert, they want you to tell them what to do‖ since they are not used to more ―egalitarian‖ treatment in their personal lives (P-4: 1316-1318; P-7: 755-766). One felt that she had to learn to modify the degree of authority she uses in therapy depending on a client‘s cultural background. Ironically, some clients feel more empowered when they‘re ―told‖ what to do because they have grown up being expected to listen to authority and have therefore not developed habits that promote autonomy as strongly as individuals have in the West. Some will say, ―I‘m paying you to tell me what to do‖ (P-4: 1253-1346), however, at the same time, clients are generally more sensitive to perceived judgment in Kuwait than they are in the West (P-4:

1890-1905). Nonetheless, many therapists get swept away by playing the role of ‗authority‘ because they‘re dealing with a population who expects it (P-4: 2165-2187; P-7: 779-782).

1.2. Emotional distress is presented more somatically in Kuwait than it is in the West.

About half of the clinicians I interviewed felt that people express emotional distress more somatically in Kuwait, by saying they feel ―weak‖, ―tired‖ or have inexplicable pains in various parts of their bodies (P-1: 654; P-4: 1549-1554; P-7: 393-395; P-11: 564; P-14: 572-586):

I see it all the time, you know, people who have absolutely no physical ailments,

yet the mental chaos of their minds has created one. You know, they are

physically ill as a result of all the chaos of their minds. (P-7: 393-395)

Some feel that this is merely reflective of the fact that it is more acceptable to say ―I have a back problem‖ or ―a neck problem‖ and get treated for those, than to say, ―I have depression‖ 181

and face their ―psychological problems‖ (e.g., P-15: 400-409). Others, however, feel that depression and anxiety, in particular, appear as chronic or frequent headaches, backaches, tiredness, insomnia, and/or fatigue, however ―when you check, maybe they are assigned to a new job where their boss is giving them a hard time‖ or ―maybe he has a problem with his wife‖.

Although Kuwaiti patients generally have difficultly acknowledging the relationship between psychosocial issues and physical symptoms (P-19: 126-131). A family physician felt that some of her patients develop serious hypochondriasis because of the inability to acknowledge this relationship, and gave an example of one of her patients:

I had a patient, he came in with big files. He did an MRI for the head two times,

an endoscopy three times, repeated chest x-rays, unneeded investigations. But he

is completely physically healthy. At the end of the day, he was just a somatic

patient. So after that, after I convinced him, that ―all you have is emotional pain,

and this is a panic attack with somatization‖, he stopped doing these… Unneeded

investigations… He was shocked that it stopped his suffering. (P-14: 50-58)

Similarly, Participant 13, who is a clinical psychologist, said that ―Kuwaiti people tend to be more somatic‖ and that mental or emotional anguish ―will be expressed in regards to headaches and stomach aches and weakness‖ (532-534). She gets regular referrals from physiotherapists who ―will do everything with the person and they realize it seems to be more of a psychological issue‖. She noticed that ―a lot of the time after we work with them on their anxiety and relaxing and making changes in their lives‖ that ―their physical symptoms will dissipate‖. She also felt that there are definitely ―less somatic complaints in [North America]‖ than there are in Kuwait (669-685). Additionally, she noticed that if young adults break some distressing news to their parents (e.g., about being homosexual, or failing at university), that it

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sometimes ―physically affects their parents that their parents might actually get ill‖. Therefore many young adults are more afraid of ―physically bringing harm by sharing certain things with their parents‖ than they are of causing them mental or emotional distress (P-13: 522-532).

Another clinical psychologist said that the tendency for issues to present more somatically can complicate diagnosis, because ―if you go strictly by the DSM, you will diagnose with somatization disorder all over the place‖ when in fact, ―you should be diagnosing depression‖

(P-4: 1554-1555).

1.3. Mental illness is perceived to be more severe in Kuwait than it is in the West

Owing to the stigma of having a mental disorder as well as the general resistance to mental health services in Kuwait (see Metatheme 4), individuals tend to delay seeking help.

Many clinicians believe that this worsens the prognosis of mental health issues: there is ―a lot more severity in the conditions here [because] people wait longer to seek help‖ therefore ―when they do finally come to us, they‘re pretty much deep into their problems or into their diagnosis‖

(P-1: 619-622). This is different from North America, where a family doctor would typically refer a patient to a psychologist or counselor, if individuals do not go there directly (P-1: 622-

624). Another therapist said something similar, however she was far more relentless in her response:

I don‘t necessarily think that aspects of the culture increase the prevalence of

mental illness here, what I think they do is increase the degree of mental illness,

you know when mental illness is present because you run into stigmatization or a

level or denial, or you know – they don‘t bring their daughter in or son in until

they‘re in full-blown psychosis. You know, they knew for months that things have

not been right, but they denied it or morphed it into something else, or didn‘t

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think it had to be checked out, so by the time they bring in the poor boy, he is in

full-blown paranoid psychosis, and the only thing or solution is [psychiatry] and a

lot of medication… So what increases mental illness is that they‘ll take him home

and lock him in his room and hope he gets better (P-7: 965-974).

This tendency to ‗lock up‖ individuals whose behaviors are too erratic, or ‗psychotic‘, was mentioned by four other participants, who all felt that isolation worsens symptom severity

(P-5: 382-394; P-11: 305-332; P-14: 693-698; P-21: 96-99). Social isolation, however, was not only brought on by family members; a local mental institution in Kuwait also has a reputation for ill-treating its members. One of the community members I interviewed conducted an ethnography for an anthropology class and reflected on some of her observations:

Instead of saying, ―okay what can we do to [help] this person?‖ they‘ll just give

them pills to shut up or... Just keep them locked up away in a room or in a

separate ward… I wanted to interview some patients at the mental institution [but

I wasn‘t allowed to]… However I could see them through the window… And you

could tell, they were just kind of shuffling around, wandering around and there

was like, staff available. But from what I‘ve heard, they just give patients, I mean,

just the same pill. Like, they won‘t even prescribe the proper pill or the proper

medication to the person. So, for example someone with autism might have the

same medication as someone with schizophrenia. I don‘t know what they give

them, but it‘s just something to keep them quiet and shut them up. (P-5: 382-394)

While she blamed the clinicians for aggravating psychosis in their patients, some clinicians were more likely to blame the patient, their family, or Kuwaiti ‗traditions‘. For

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example, a psychiatrist felt that although the prevalence of mental disorders are the same in

Kuwait as they are anywhere else in the world, they are much more severe in Kuwait owing to

―interfamilial marriage‖; in other words, certain families ―marry within the same family‖ and increase the ―genetic load‖ which leads to more severe mental disabilities (P-10: 277-281).

Others felt that the reliance on ‗quack‘ therapies rather than proper mental health care worsens the prognosis of mental disorders. For instance, a family physician said that some of her patients refuse to take antipsychotics because they find the side effects more uncomfortable than the disorder: ―that‘s why they‘re getting worse and worse and worse‖ and that ―they will read the

Holy Quran, they will go to the Sheikh [religious healer]… Anything except taking medication‖

(P-14: 693-698). Another member of the community who is currently pursuing higher education in clinical psychology also felt that the overreliance on alternative therapies can worsen mental disorders and even traumatize patients further. He reflected on one case of someone he knew personally:

They [sheikhs] put the Quran all over his body and then they took one band and

they put it on [his toe]. And they just tied it tight, tight, tight. They then [drew]

blood. Black blood. And then they said, ―Oh, see? The Jinn [demon] is coming,‖

because the Jinn is bad and the bad should look black. So [to them] that‘s huge

evidence [of] Jinn. As I told them, if you tie any living thing, any part of your

body for a good period of time, then the blood will be dark [but] they don‘t

understand it that way (P-17: 526-532).

Participant 20, whose father-in-law is a sheikh, said that it is normal for them to ―kick them, put electricity on them sometimes, [poke them] with sticks and [apply] liquids… It‘s not

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acid; it will not eat the meat [of the body], but it will burn‖. He said when he debates the sheikhs, and says ―this guy is dying, you are killing him or her!‖ they will say, ―no no, it‘s not her, it‘s the jinn who is shouting‖ (P-20: 449-460). These practices are undoubtedly extremely inhumane therefore it is only normal and expected that they can cause more trauma. Therefore, in addition to the stigma associated with mental illness, inhumane practices – which are unfortunately widely accepted – are also contributing to poor outcomes for mental health patients.

2. Inequality drives mental health issues in Kuwait

I would like to introduce this metatheme with something very poignant an ex-psychiatric patient shared with me. When I asked him what his definition of mental illness was, he said, ―mental illness is a perfectly appropriate response to life in today‘s world‖ (P-26: 413-414). Similarly, a young Muslim woman from the community associated health with being ―treated as a human being‖ (P-5: 179). These definitions were in sharp contrast to some board-certified therapists‘ associations with mental illness: ―having maladaptive behaviours or emotions or disorders that affect your lifestyle in a negative way‖ (P-1: 236-237), or having ―appalling ignorance‖ or

―cognitive dissonance‖ which ―produces mental illness‖ (P-7: 706-707).

During the ex-patient‘s interview, which lasted over an hour and a half, he described numerous acts of violence, racial discrimination, oppression, police brutality, and human rights violations that were directed either at him or individuals he knew personally or worked with in

Kuwait (discussed below). His interview anchored many of the political issues in Kuwait that were discussed in all of my other interviews. Results indicated that most mental health issues in

Kuwait are a byproduct of inequality, oppression, and the preoccupation with status because the majority of the issues that were narrated by clients, patients, and health professionals revolved

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around these dynamics. Specifically, they typically involved patriarchy in either subtle or more overt forms. This became the leading theme in my analysis.

2.1. Patriarchy drives extreme gender expectations and inequality which negatively affect men, women, and children

All the therapists (including family physicians) felt that the most common issues they dealt with were depression and anxiety stemming from problematic family dynamics and other relationship issues in Kuwait. Many participants (including some healthcare providers) blamed ‗culture‘ or the ‗individual‘. Other, more culturally conscientious participants, highlighted the importance of looking at historical, political and economic factors that have shaped cultural and social stratification in Kuwait. The most pervasive theme across all the interviews, however, was that of extreme gender norms and expectations. Although none of the participants used the word

‗patriarchy‘, most of them, including men, described Kuwait as a society where men (particularly

Kuwaiti men) hold more power since ―women and children are chattels‖ of their dominant male relative (husband, father or brother) and are only ―entitled to the protection of the law insomuch as he does not interfere or prevent it‖ (P-7, Psychologist: 191-192). In other words, women are particularly vulnerable to being treated as ―second-class citizens‖ (P-4, Psychologist: 393). This power differential can have profound effects on the overall wellbeing of women, children, and in some cases, men, in Kuwait. In extreme cases, these power dynamics can also prevent social and legal interventions of domestic violence.

Before exploring overt forms of oppression and inequality, I would like to highlight what more subtle forms can look like in Kuwait. This was drawn from one of the service users I interviewed. She was a middle-aged North American woman who married a Kuwaiti man when she was in her early twenties and converted to Islam (which is not uncommon among Western

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women who marry Kuwaitis). She made the important distinction between religion and tradition in Kuwait when she discussed her lived experiences as a woman. She also summarized the stereotypical perception that individuals can have of a typical ‗Kuwaiti‘ household:

I see my mum‘s reaction in me sometimes, not standing up for myself? But that‘s

a part of this culture too. The man is dominant. The man is right. The man has

control. And yeah, he does have control of everything. I mean, just last year I got

my own bank account. I‘ve worked for how many years – I‘m retired. Never had

my bank account, never had my card… In Islam, it‘s the right of the woman – her

money is her money. And I never knew that [until recently]… We don‘t want to

be barefoot in the kitchen. We want to make a difference. It‘s a hard life… My

younger daughters want to go out and work and the problem is that the male

keeps telling the female what they must do. Or they are kind of setting the

standard – she must be ‗respectable‘… – the ‗marrying‘ kind… But [many] men

are off going to Dubai having their fun outside of Kuwait. The alcohol, the hotels,

the women…. [And then they] come back to their wife and kids… And the

women are heartbroken… [Do] the guys think we‘re stupid? (P-18: 40-44; 732-

736; 753-754)

She described several different aspects of patriarchy that she feels are entrenched in

Kuwaiti society: first, she alluded to the perception that males are ‗dominant‘, ‗right‘ and have

‗control‘. Second, she did not know for years that she had the right to have control of her own money, which fell in line with what many therapists said: that ―[we are] hearing a lot more women complaining [that] they don‘t know what their rights are‖ (P-4: 1120-1123). Third, she felt that men are ―setting the standard‖ for how women should behave. Fourth, she highlighted

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the cultural expectation that a woman must be ‗respectable‘ in order to prove that she is the

‗marrying‘ kind. Finally, she noted that in Islam, women have a lot of rights, but oftentimes

(articulated further by a female Muslim therapist and scholar), ―cultural expectations are very different from religious rights‖ and that ―women have a lot of religious rights based on Islam, or being a Muslim‖ (P-6: 948-940); that ―authorities [men] take away those rights‖ (P-6: 1007) and effectively, ―culture can absolutely twist things to [a man‘s] advantage‖ (P-6: 940-941). In effect, women are generally blamed for familial conflicts. A Kuwaiti male physician also felt that Islam encourages ‗kindness‘ and ‗health‘, and the idea that a woman or a child must suffer by the hands of a man goes against what the ‗Prophet‘ said (P-19: 442-456). However, ―people tend to combine religion with politics‖ and ―use religion to [achieve] their goals‖ which bleeds into family environments (P-19: 502-505). One female counselor, for instance, felt that men mostly

―put the blame on the female‖ during couple‘s counseling and that ―very few men are open and supportive‖ (P-1: 590-594).

The ―double standards‖ (P-4: 412) of respect, honor, integrity and reputation (i.e., morality) that have been set in Kuwaiti society, for women, largely revolve around her virginity

(e.g., P-2, Service user: 112; P-12; Service user: 1042) to the extent that young women will travel to foreign countries ―to have their hymens restored before marriage‖ (P-7, Psychologist:

1139-1140). These cultural expectations for women generally make them feel as though they are

―living under a microscope‖ because ―once her reputation is tarnished, all her sisters’ reputations are tarnished‖, thereby reducing her family‘s status in the community (P-18, Service user: 388-

389). There is a strong cultural perception that a woman‘s (and her family‘s) reputation becomes questionable if she is publicly seen socializing with men: ―you can‘t get married if people are seeing you out with these guys‖ that ―[if] you‘re having fun, you‘re not marriage material‖

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because ―marriage material ones are respectable‖ (P-18, Service user, 388-389). Most therapists alluded to the fact that anxiety and depression are most common among their clients and patients

– particularly among women – owing to these circular logic statements and double standards.

These nuances can, in turn, affect how mental health issues are presented in Kuwait. As one therapist (who has practiced in North America and Kuwait) said:

There's an actual reason people have social anxiety here more. Because people do

look at you! People do judge you! That's the truth! More so than other places.

You know, so, trying to talk to an anxiety client who has social anxiety here in

Kuwait is going to be totally different than in [North America] (P1: 394-395; 381-

395).

Interestingly, this judgment can also come from women in Kuwait. For example, a young woman I interviewed reflected on her mother‘s initial response when she told her that she had been raped (although she became more supportive after extensive family therapy):

I suffered from trauma at the age of ten… it was rape... I didn't tell anyone about

what happened until last year. It's been 19 years… [When] I told my mom about

the rape... She had a really bad response.... luckily I told her while I was [in

therapy] ‗cause I was able to get the support... But you kind of realize what your

culture is and where you're coming from [when your mother‘s response is] ―does

that mean you're not a virgin? ‗Cause we can fix that‖ (P-2: 109-112)

Although most of the narratives surrounding patriarchy revolved around how it negatively affects women, it appears that some women can be just as authoritarian. For instance, a female family physician who incorporates interpersonal therapy in her medical practice felt that

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women can be equally, if not more, oppressive than men because they are ―over-controlling‖ and are the true ―dominators‖ in many households; that they ―control their husbands, their kids, their grandkids, in a very annoying way‖ without giving them the opportunity to ―express their feelings‖ (P-14: 557-561). When I later probed about the life events that trigger panic attacks and depression among her patients, she said:

Marital conflicts [affect] males more… I have more male patients than female

patients… And they‘re expressing their emotions in amazing ways. Once they‘re

opening the doors to talk, they [start] crying… They‘re masking themselves with

the power of being brave or strong. But they [can be] very fragile from inside. (P-

14: 114-121)

Her narrative suggests that extreme gender norms are not only socially and emotionally damaging to women, but also to men owing to the cultural belief that men must always be ―brave or strong‖. This male persona is generally associated with the role of being ―a father‖ and ―a provider‖ who ―pays the bills‖ (P-6: 1191-1192). However, many men who open up to their healthcare providers (as we saw above) also feel that they are burdened by the expectations that are placed on them. For instance, a male therapist also felt that many of his male clients seek support to alleviate this ―chronic feeling of disappointment‖ – that they are ―disappointing their fathers‖, ―not doing enough‖, or not being ―successful enough‖ – while female clients ―often complain that they don‘t get enough love or affection‖ (P-3: 376-382). One female participant who has lived in Kuwait her whole life also described the fact that ―losing control‖ is not socially acceptable in Kuwait: ―being a man here is being more authoritative [and] taking control of things. So when you lose that control… you are losing control of yourself and that‘s not acceptable in this society‖ (P-5: 699-702). From a Kuwaiti man‘s perspective:

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It's really hard to live here. Uh, for an independent person… But you [do it]

because you have to… I'm not a family person but I have to take care of the

family… You do your duties… Just because this culture… It just forces you to be

a family person (P-15: 26-48).

In a different context, a non-Kuwaiti Arab male felt that he finds this social pressure really ―irritating‖: ―especially for me, as a man, I’m the one who is responsible to guide or lead my family‖ (P-20: 159-161). It was well established within the interviews that extreme gender norms and expectations negatively affect both men and women in Kuwait. In terms of clinical practice and social work, gender inequality is capable of making domestic abuse interventions more problematic for healthcare providers. According to a Kuwaiti man, ―it‘s not part of our religion, you know, beating our women‖; however socially, ―they think [it‘s okay] to control their women… [It‘s] sometimes considered normal‖ (P-19: 434-436). Since there is a cultural understanding that decisions are left up to the dominant male relative in a household (who are generally identified as the perpetrators of abuse), even legal aid or a clinician‘s testimony cannot trump a man‘s word when it comes to his family, as the following examples demonstrate:

Children are being abused, and there‘s nothing anyone can really do about it.

Sometimes we get clients – girls, who are clients – who are being molested by

their fathers. And the onus is on the girl to prove sexual abuse. So they have to

take a recorder and put it under their pillow while they‘re being raped, or have the

police standing outside their window, peeping in while she‘s being raped… And

obviously, that is traumatic for a child... In [North America] we‘re mandated to

report it... [But in Kuwait] there‘s nowhere to report it to. If we go to the police,

the police are going to go to the door, and say ―are you abusing your daughter?

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No? Okay.. Goodbye‖. And they take the child out of therapy, and that puts them

at further risk for more abuse, without any support whatsoever. So we have to be

cautious about who we report to, why, and when (P-3, Male therapist: 111-127).

Participant 11, a female physician, also noted that men are at an advantage over women and children in Kuwait since they are their legal guardians, which makes reporting abuse very complicated:

The law [says] if a doctor sees this, the doctor should report it to the police. But

then what? Only if the family wants to have a case against the father – or the

abuser. But most people are too scared to do it. Because he is usually the care

provider. The head of the family. He’s responsible. The kids are under his name…

The father is the guardian, not the mother. It is very difficult to take kids out of

the home environment even if they are abused… The law changed to say that

doctors should report it. But then our argument is, ‗then what?‘ you report it, and

then what? What‘ll happen is that he will never bring them to the hospital again.

(P-11, Female physician: 657-667)

Similarly, a male therapist alluded to the lack of a legal support system in Kuwait, ―that if a child is abused – or somebody, anybody, is abused – there‘s really nothing that can be done‖.

He felt that ―victim safety‖ is what bothered him the most; that ―not even religion, but tradition gets in the way‖ (P-9, Male therapist, 1180-1189). Another therapist also said that she is often fraught with feelings of hopelessness and helplessness with ―clients that have disclosed that they are being raped on a regular basis by their father or uncle‖, and was angered by the fact that ―as a psychologist, as a therapist, I have no legal status‖ (P-7, Female therapist: 594-597). These narratives demonstrate that dominant male relatives‘ words carry far more weight than women‘s,

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children‘s and even healthcare providers‘ in Kuwait, even if the healthcare provider is a Kuwaiti man. This complicates intervention because ―even though the law may say that they are entitled‖ to protection, ―a father or brother may intervene‖ or mothers may be ―too scared‖ to file a case against the father, thereby limiting the woman‘s or child‘s access to healthcare or legal aid (P-7:

192-194; P-11: 661). In many cases, physicians are bullied by the parents when their children resist them. For instance, a local family physician, recounted a case where one of her patients, a fourteen year-old-girl, attempted suicide several times:

The last time she came she just [took] a lot of tablets and she had repeated

vomiting and gastritis. And I knew that it wasn‘t just gastritis, it was attempted

suicide. She was avoiding eye contact, she had low mood, she was crying all the

time, and I knew she‘s depressed. I wrote in the referral papers that it was a

suicide attempt. And it was the third time, and she just ingested all these tablets…

I referred her to medical emergency because of the gastritis. After they stabilized

her vital signs and everything, they discharged her with an OPD [outpatient

department] appointment with the psychiatrist… The mother came to the clinic,

and she was shouting at me. And her father also, he was also shouting at me. Like

―what are you saying, you are opening the eyes of the girl‖... It‘s too much for

me. And ummm even my manager, she cannot protect me. She said, ―they have

the rights. If they don‘t want to go, khalas [it‘s over; don‘t interfere]‖. Nobody

protected me. And I was being judged and evaluated by investigators because

she‘s an adolescent (P-14: 1156-1172).

In another case, a psychiatrist was victimized, upon orders of a local family, by being

―bullied‖ and ―beaten up‖ for authorizing the release of a twenty-three year old woman who

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―posed no threat to herself [or] anyone else‖. The psychologist who recounted the story exclaimed that the supervising physician ―fulfilled his ethical obligations… Why should you tell the parents?‖ especially when the patient said that ―she was in danger if her family found out that she left‖ (P-4: 2265-2279). In another instance, Participant 26 recounted a case that clearly demonstrates the extent of patriarchy entrenched within the actions and language used by local law enforcement:

[My partner] worked for a very short time, I think with one client… It‘s very

tough – particularly for Kuwaiti clients, especially in terms of the sexual abuse…

There is at least one case… where a daughter was being molested by her father

and the mother and the daughter went together to get counseling and they said,

―you know we went to the police to file a report but the police slapped my

daughter and said ‗don‘t you dare‘, you know, ‗bring your father‘s name into such

shame by saying such things.‘‖ (P-26: 707-713)

Violence and oppression were generally discussed together during the interviews and were associated with all forms of physical, emotional, sexual abuse and bullying. This included inhumane treatment from local law enforcement. Although women and children appear to be the most vulnerable within the Kuwaiti population itself, several participants also noted that there is a socioeconomic and racial component to inequality and oppression in Kuwait, in that non-

Western foreigners can be just as, if not more vulnerable to oppression. This led to the formation of a different, yet overlapping theme, which highlights the major human rights violations with foreign workers as well as more subtle forms of oppression such as bullying, racism, and nationality-based discrimination.

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2.2. Foreign workers from third-world countries are highly vulnerable to oppression, inequality, and abuse in Kuwait.

Participant 3, a male therapist, described the human rights issue in Kuwait very succinctly. When I first asked him what he doesn‘t like about Kuwait, he mentioned the

―corruption‖, ―injustice‖, ―pervasive human rights violations‖, and ―oppression‖ (93-97). When I probed further, he felt that governmental policies are one of the drivers of social stratification in

Kuwait:

[I don‘t like] the social stratification of Kuwait… There are a million Kuwaitis

and two million expats and umm… Many of them [expats] live in poverty,

essentially, are exploited, and taken advantage of by government policies that

allow Kuwaitis to mistreat their domestic help. And there doesn‘t seem to be

progress. So that‘s frustrating. The government is basically non-functioning… As

a result, this country still seems to be in a stand-still. It hasn‘t really developed in

the last 15 years. (P-3: 101-106)

Similarly, when I asked another therapist what she did not like about Kuwait, she described more specifically how foreign domestic workers can be exploited:

With the Filipino maids it‘s almost always sexual assault or beating. With the

drivers it‘s mostly – almost always physical assaults. And almost systematic

abuse, for both… The thing that maintains all of this is the Kafeel System which

is essentially slavery… In a significant number of cases, that‘s how the domestic

staff is treated… I‘ve been extensively involved in cases of abuse, of death, of…

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Attempted murder, of horrific – incredibly horrific – abuse and trauma. (P-7: 255-

260)

The most detailed account of racism, nationality-based discrimination and human rights violations against foreigners was provided by Participant 26. He was from South Asia, but was a born and raised in Kuwait, and travelled to several different countries throughout the world. He was successfully treated by a psychiatrist in Kuwait for obsessive ruminations and suicidal ideation and is now off his medication (P-26: 601-602; 662-664). He said, ―how I feel about

Kuwait is where my mental health is at‖ to describe the pervasive feeling of hostility directed towards him specifically in Kuwait and no other country he lived in or visited (P-26: 89-90; 90-

91). To him, ―[Kuwait] is by far one of the most racist places I have ever encountered in my life‖

(23-24). He discussed how he and his friends (also foreign) were arrested in Kuwait for not carrying national identification, however the arrests were based primarily on the fact that they were South Asian and did not speak Arabic: ―they wouldn‘t let me make a phone-call‖, he said early on in the interview. ―If you don‘t speak Arabic – which I don‘t – they don‘t bother communicating with you‖ and ―they just shove you into a van and take you‖ (P-26: 64-71).

However, by telling the police that he was North American the second time he got arrested ―went a long way towards them treating [him] better‖ (71-72). His partner, who is Southeast Asian said she receives preferential treatment when she tells the police she‘s from North America:

―Kuwaitis hate [Southeast Asians] and treat us like whores‖, however ―when they see my [North

American] passport, they treat me like I‘m a goddess‖ (P-26: 72-75). Another participant also recounted a story of how she was given preferential treatment for being ―white‖:

To experience positive racism…The first time I experienced that here, I just really

felt sick. I didn‘t know what to do. We were standing at the lineup at one of the

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ministries… And just waiting our turn. Inching up like everybody else. But we

were the only white people in the room and the rest were Indians, Sri Lankans,

and East Asians and umm.. Filipinos. And someone just saw us and came and got

us – we didn‘t want to go – but he insisted… He pulled us out of the line and

bumped everybody out of the way and bumped us up to the front… Somehow we

were… You know, worthy – more worthy – than everybody else. (P-7: 207-215)

Participant 26 described the reverse situation – that if you‘re ―black‖, you might be taken to the back of a crowd (including in mosques):

I know a guy who‘s black and British, like he worked for the British embassy, and

when he [went] into the mosque and stuff like that, they told him to go to the back

of the crowd. (P-26: 116-120)

Although foreign and domestic workers are more vulnerable to oppression and violence since they are less protected by the law, many participants across all demographics (including

Kuwaitis) discussed some of the economic factors that can have negative psychosocial consequences for all individuals – particularly children and adolescents – in Kuwait, including in high-income families. These factors largely revolved around the overabundance of money in most Kuwaiti households which leads to the over-reliance on cheap domestic labour. This was, by some, attributed to the fact that Kuwait has grown very rapidly in the past few decades.

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2.3. Rapid industrialization and cheap domestic labor are perceived to have negative psychosocial consequences for individuals from high-income families.

A Kuwaiti physician admitted during her interview, ―you can pretty much not work… and still make money‖; although, she continued, ―you‘ll get a good salary and a good benefit to stay at home, [but] it creates a very entitled, lazy society‖. Another therapist, from a different Arab country, felt that many Kuwaitis are ―too spoiled‖, ―have too much free time‖, ―not enough responsibility‖ and ―not enough motivation‖ (P-1: 503-509). Participant 6 took it a step further and said that ―a lot of prestige is not tied into who you are, rather than what you have‖, such as

―brand-oriented designer stuff‖ and degrees from ―Ivy League universities‖ – basically, anything that an individual or their family can ―flaunt and project‖ (P-6: 533-544).

Most of the therapists‘ narratives – particularly those who were educated in the West – resonated with Participant 6‘s perception that ―the access to privilege and a fortunate lifestyle‖ can be very ―counter-productive‖ to family dynamics or overall well-being (P-6: 254-255; P-1:

503-509; P-3: 328-336; P-5: 1578-1582; P-13: 308-322). One outcome of relatively high income is easy access to foreign domestic laborers, such as housemaids, nannies, cooks and drivers (e.g.,

P-6: 394-399; P-13: 308-310), to the point that many families ―refuse to [let] them go back to their country because they get used to having them in their homes‖ (P-14: 23-625). This usually happens by withholding their passports (P-14: 626-630). This over-reliance on domestic labor can also reach the point where many ―drivers‖ and ―nannies‖ take on daily duties such as following up on children‘s report cards (P-6: 779-787), which reduces the ―interactive lifestyle‖ and opportunities for forming an ―emotional connection‖ with their children (P-6: 258-260).

Participant 6 recounted an incidence where a parent said to her, ―I don‘t know what kind of cereal my child likes, let me call [the driver] and ask‖ (398-399). Consequently, many young

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children, instead of being raised by their parents, are essentially raised by domestic workers – and, in Participant 6‘s case – the emotional bond that should be created with parents can instead develop with their domestic workers, and sometimes their clinicians (254-260). Participant 13 took an even stronger stand against youth being raised by domestic workers, because she feels that they are not appreciated or conducive to youth learning valuable ‗life skills‘:

They have grown up with workers, working for them, busting their butts, you see

them on the streets, you know, and they don‘t see those people a lot of times.

They don‘t appreciate those people because it‘s so much a part of their world…

It‘s kinda metaphorical with them throwing stuff on the ground and it just gets

picked up… Young adults get into a lot of trouble and they are so used to getting

bailed out with ‗wasta‘ [clout]… [That] they‘ll go to the U.S. and drop out after

the first semester… They don‘t realize that if they mess up that they might not get

a second chance because they are so used to second chances all the time. So a lot

of them will come back [to Kuwait], you know, feeling really really depressed…

And I will see a lot of clients like this where after their first semester they just

they stopped going to classes or they just weren‘t equipped to live in U.S… They

didn‘t have enough of those life skills to do it on their own because they are so

used to everybody doing everything for them. (P-13, Therapist: 308-322)

Similarly, another therapist said that many of his Kuwaiti clients ―did not succeed when they landed in New York or London‖, which was a ―big transition for some of them, who may have had everything looked after for them‖; that some of their ―internal controls are weak‖ (P-9:

482-491). Paradoxically, however, some therapists also felt that parents have very high

―expectations‖ of their children and ―children develop issues because of these expectations‖ (P-

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1: 665-668). In some cases, ―expectations in terms of achievements could be so stringent that emotional [involvement] fades away‖. For many parents – particularly those from more status conscious families – having a child who graduates from ―Harvard or MIT or any Ivy League university‖ is more important than building relationships with them (P-6: 514-516).

The previous sections allude to two important points: first, there is an overreliance on foreign workers to take over ‗parenting‘ roles; second, many parents become preoccupied with maintaining (or enhancing) family status at the expense of forming intimate relationships with their children. These two factors combined appear to create emotional and behavioural responses in children that can often mimic learning disorders. To Participant 6, ―emotional disturbances‖ are usually ―labeled as learning disabilities‖, even though they are often the result of ―a lack of parental involvement‖ (215-217). As a practicing physician, however, Participant

14 felt that her son had a genuine case of a learning disorder, which she ‗discovered‘ while she was pregnant:

I discovered that [my son] had ADHD when he was in my uterus… After school

Kindergarten a lot of behavioural problems appeared. So I took him to the

psychotherapist for play therapy. And it was very effective… But in the 3rd grade,

he started to have attention problems... So it was time to introduce the drugs…

The problem is that nobody will accept it. If I just talk about this ADHD my

mothers and sisters and cousins…They‘re just underestimating the problem… ―If

you give him the drugs he will be an addict‖, blah blah blah, and all these

problems about the medications. They said, ―what are you doing, what is play

therapy, what is psychotherapy?!?! He is young, you can‘t take him to the

psychotherapist!‖ So I stopped telling them what I was doing… In school, they

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said he should take the medication or he will be fired from the school… And my

husband is not cooperative at all... I took him to the psychiatrist… I didn‘t tell

anyone, after the treatments, and almost being fired from the school, he got a lot

of medals and rewards and certificates from the school… So I noticed the

change… From almost being fired from the school, and being a bad person, now

he‘s a good person. (P-14: 805-833)

Although Participant 14 described what appears to be a success story since her son is now a successful student, and therefore a ―good person‖ owing to the positive effects of his medication, other clinicians feel that learning disorders are ―over-diagnosed‖ and ―[many] parents want the child or even the young adult contained, medicated‖ to the point that providing therapy can be difficult because ―[many] clients here are so medicated that they don‘t make sense… they‘re half asleep‖ during therapy (P-1: 464-466). According to Participant 1, many physicians in Kuwait are quick to diagnose and medicate impulsive or hyperactive children: ―it‘s an over—medicated society just like the US‖ (P-1: 448-452). Similarly, Participant 13 described how difficult it can be to make a diagnosis in Kuwait because many social factors can lead to what looks like a learning disorder:

Is this ADHD or is this more, you know, kids never having somebody really set

ground rules with them and have consequences and things… You have to start

teasing that stuff out... It is hard to figure out, well what‘s environmental,

behavioural you know versus a diagnosis of ADHD?… So many things can

mimic ADHD… Even if it was a lot of, you know, trauma in the home…

Children who are neglected behave in certain ways… Now you can call that

depression or you can call it neglect… A lot of times too kids will externalize

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what they are feeling, you know? So that could kind of come out in aggressive

behaviours that one could point to being impulsive you know, um, ADHD, when

maybe it‘s something else. (345-357; 372-374)

In addition to depression, anxiety, and behaviours that mimic learning disorders, problematic family dynamics appear to be contributing to substance abuse as children grow older in Kuwait. As another therapist said,

Addiction is a reaction to trauma, pain, abuse, or neglect… It‘s a reaction. It‘s not

‗Oh… I‘m gonna go and get addicted to something‘… ‗Cause most addictions are

about numbing pain, about ‗I don‘t want to feel like this, I want to feel like

something else‘. So it‘ll be a drug, or alcohol… The cause of it is usually in the

family. (P-9: 409-419)

Participant 3 also discussed the drivers of substance abuse, however he contextualized it within much broader historical and economic factors. He made the important point that ―the level of [socioeconomic] growth was considerable in the past forty years‖, which explains why the youth in Kuwait, today, are more affluent and have ―very different lives than what their parents and grandparents had‖ (P-3: 397-399). In addition to how this impacts intergenerational conflict

(which we will see later), it can also lead to substance abuse in Kuwait:

Alcohol is pretty widely available [and] drugs are pretty widely available… It‘s

not hard to find. When you have a population of people with a lot of money, uhhh

particularly a lot of money, they have a lot of time on their hands. Because many

people don‘t work, or the nature of their work is very limited… I think a lot of

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clients we see are… at that age where they‘re trying to figure themselves out but

there aren‘t any opportunities to find direction. So they‘re sort of bored and sort

of aimless in their life, and sort of floating? And that in combination with money

and time, I think, is a recipe for getting addicted. (P-3: 328-336)

The findings thus far have demonstrated that inequality and oppression appear in the forms of patriarchy and nationality-based discrimination in Kuwait, both of which are endorsed by Kuwait‘s legal system. In extreme cases, the outcomes of these are major human rights violations, particularly among foreign domestic workers. The fact that Kuwait is highly socioeconomically stratified can also affect mental health in that those who are wealthy or highly preoccupied with prestige or status are perceived to place less importance on forming emotional connections with their family members. Consequently, many mental health issues in children, adolescents and young adults are thought to result from their social environments. In many cases, individuals can become so preoccupied with status that they will resort to medicating themselves or their children to achieve success. In some cases, the preoccupation with status makes individuals oblivious to the major human rights violations that surround them in Kuwait, as we will see below.

2.4. High status and financial security can elicit complacency towards human rights violations in Kuwait

Although many people are ―either actively, some way or another addressing human rights violations‖ in Kuwait, many are either ―pretending it doesn‘t exist‖ by ―pathologically denying‖ it or are unaware that they‘re occurring (P-7: 222-228). Participant 3 attributed this denial to financial security: ―so long as people are continuing to get a certain living and salary‖, then ―no

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one really seems to care that people are getting oppressed in Kuwait‖ (P-3: 97-98). This lack of awareness or regard for human rights is also thought to occur among many financially secure foreigners. For instance, Participant 26 felt that ―the hostility is not felt by a certain part of the expatriate population, including Indians‖ who are ―financially better off‖ or ―able to move in

[elite] circles‖ (P-26: 85-88). This appears to hold true within the data itself. Although all participants discussed some form of inequality or oppression (e.g., patriarchy or nationality- based discrimination), only nine (approximately one third) of the participants in this study brought up the issue of human rights violations in Kuwait. Out of the nine individuals, eight of them were healthcare providers (only one of whom was male) and one of them was Participant

26 – the ex-psychiatric male patient who personally witnessed human rights violations. Given these demographics, it also appears that the awareness of human rights violations in Kuwait is higher among those who have repeatedly been exposed to them either personally or professionally.

3. Ideological and cultural conflicts affect mental health and the practice of mental healthcare in Kuwait

Based on the perceptions of all the participants in this study, Kuwait is currently a melting pot for economic, political, and cultural change that is grounded in its historical upbringing. This change is influencing a rapid generational shift in worldviews that manifest as intergenerational conflicts and are presented within clinical settings. Participant 3 summarized the complexity of this change in Kuwait:

Many of our clients are younger, probably under the age of 30 – 20s and 30s

mainly…There also seems to be pronounced differences in communication

between generations. So many are now being educated for the first generation; the

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first generation is educated, they travel abroad.. Whereas their parents may have

lived in relatively modest houses, and had to – or more agrarian, have lived by the

water, could tell time by the sun, but now the children are off going to Paris, and

going around the world. So as a result there‘s a lot of miscommunication and

misunderstanding between the two generations. Clients will often talk about how

their parents misunderstand them, how they can‘t talk to them… On the flip side -

well often - parents will say things to us like, ―my daughter is becoming too

modernized‖, or ―losing Kuwaiti tradition, or Kuwaiti culture‖, umm.. ―they‘re

speaking too much English‖ – so the generational difference is very complex. (P-

3: 394-407)

The following themes were constructed in an attempt to capture the intricacy of intergenerational conflicts by explaining how materialistic and post-materialistic values (3.1) are compounded by deep-rooted perceptions of Arab and Western cultural norms (3.2). Additionally, cultural idealization (3.3) and ideology (3.4) are explored within this metatheme to shed light on the shifting perceptions and practices of mental healthcare in Kuwait (3.5).

3.1. Intergenerational conflicts are largely conflicts between materialistic and postmaterialistic values

Although none of the participants mentioned or differentiated between ―materialistic‖ or ―postmaterialistic‖ values, there is a clear perception that older generations are typically more

―conservative‖ (P-1: 139) and invested in physical and material security. Younger generations

(especially those who end up in therapy), however, were described as more ―liberal‖ or

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―modern‖ (P-1: 125; P3: 405) and beginning to put more emphasis on independence and self- expression. This perception was true across demographics. For instance, a young Kuwaiti man described the life trajectory that he felt is imposed on young adults in a typical Kuwaiti family:

Finish school, finish college, get your degree, get a job, get married… Wait for

the government to give you a house… Buy the best car, have many children, and

that‘s it. Most people are like this… I know this is a stereotype, but it‘s not a

wrong stereotype… Living in this culture is a challenge [for me]… Being

independent really, uh, goes against that. (P-15: 239-252; 36-37)

Later in his interview, he said that this expectation ―restricts the lives of people‖ and makes them feel as though they are ―trapped like a mouse in a maze‖ (P-15: 342-344). This perception was also supported by most other participants, who generally feel that ―Kuwait has gone under so many changes, so fast‖ (P-18: 396) that its current economic and social climates are now associated with ―urbanization‖, ―technology‖, ―people‘s lives advancing‖ (P-1: 148-

151), ―moving more towards an individualistic type of view‖ (P-4: 1384-1385), and being ―more open‖ (P-5: 29). Consequently, there is a stronger desire, now, for financially secure adolescents and young adults to ―express themselves‖ (P-11: 468) because ―they need freedom‖ (P-4: 1442).

For instance, when I asked a young Kuwaiti woman and service utilizer what a successful day felt like for her, she said ―being able to do what I love to do… being able to just not hide to everyone‖ and ―being open‖; she expressed that she doesn‘t like it when she feels ―restricted‖,

―as a female‖ in terms of what she ―can and can‘t say‖ (P-2: 427-428). However, she also felt that younger generation Kuwaitis are changing their belief systems by being ―a lot more willing to seek change now‖ (P-2: 205-207).

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The desire for self-expression and change is also seen in the educational and career paths that younger and older generations disagree on. The more materialistic or ―traditional‖ (P-13:

195) career paths that many parents enforce are engineering, business, finance, or medicine (P3:

61-63; P-21: 142), because being a ―doctor‖ or ―engineer‖ (P-13: 195-196) is far more respectable, predictable and conducive to material wealth than pursuing an education and career in ―literature‖, ―art‖, ―music‖, or ―becoming a chef‖ (P3: 63; P-13: 179-183). Participant 2, for instance, recounted her experience with telling her family she wanted to be an artist:

What I always wanted to do was art. And I couldn't because you know, with my

family and everything like ―what are you going to do be an artist? Go get a job!‖

And my siblings are lawyers and businessmen... And you know.. you've gotta do

that (P-2: 130-133).

This ―nurturing of skills‖ (P-13: 186) related to more ‗traditional‘ careers is reinforced by the Ministry of Education which provides funding for students pursuing careers in business, economics, and the harder sciences, and not for those who wish to study the arts and humanities

(e.g., P-21: 137-151). One Kuwaiti woman, for instance, expressed her frustration towards the

Kuwait Ministry of Education:

For a country that has so many economic resources and for a country that invests

so much in education, for them to really not understand about so many

disciplines… Kuwait actually thinks there are only three disciplines. Business,

engineering, and medicine. They do not understand that there‘s any other

discipline. They undervalue any other discipline. (P-21: 138-143)

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Since avenues for self-expression are limited in Kuwait, many adolescents and young adults today are ―unhappy because they cannot be individuals‖, and have to ―conform‖ which makes them ―tired, and sad, and stressed‖, according to a Kuwaiti physician (P-11: 560-563). In other words, being ―rebellious‖, or being an ―individual‖, in Participant 11‘s view, ―does not contribute to mental health‖ in Kuwait because ―you won‘t be accepted‖ by older, more traditional communities, which is very important in Kuwait (468-475). In fact, the younger generation struggles when they don‘t ―share certain views‖ with their family, especially their

―elders‖; more often than not, they ―perceive themselves as being punished‖ and feel ―torn‖:

Should I just go with the flow and prevent problems and just silently, you know,

die a little bit every day… Or, should I fight it and feel more at peace with myself

on the inside… But then rock the family boat? (P-4: 1044-1050)

Given these intergenerational struggles, therapists are challenged to ―work with the family through the individual‖ (P-3: 207-210), without bringing older and younger generations into direct conflict with each other:

To get them to think of themselves as how I think of what is going on, without

bringing them into direct conflict with their families or their collective, has been –

I‘ve often been confronted with my cultural bias in trying to figure it out… I was

presenting solutions to my clients that was going to bring them – that might solve

their immediate problem, but was going to bring them into direct, and probably

aggressive conflict with their wider family… And what‘s the point of that? (P-7:

838-849)

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3.2. Conflicts between materialistic and post-materialistic values are expressed as, and exacerbated by conflicts between Kuwaiti and Western values

Traditional Kuwaiti values were mostly associated with practicing Islam (P-1: 644; P-4:

275; P-6: 251; P-7: 1078; P-17: 99), speaking Arabic (P-2: 10; P-3: 406; P-18: 159), being engaged and respectful in family gatherings (P-1: 151; P-18: 342-343), being high-achieving to uphold family status (P-1: 655-657; P-3: 60-63; P-6: 510-516), getting married (P-7: 909; P-12:

192; 717-719; P-15: 236-237; P-18: 389-391), and (for women), dressing conservatively (P-5:

140; P-12: 178-179; P-18: 748-749), and not pursuing romantic relationships before marriage (P-

1: 135-136; P-18: 390-391). Western values were largely associated with being an ‗individual‘ or being ‗independent‘ (P-5: 660; P-11: 90-91). Specifically, these values included having the choice of getting married or choosing your marriage partner (e.g., P-1: 133-137; P-9: 296-301), the ability to ‗choose your own path‘ (e.g., P-1: 351), being ‗free-spirited‘ (e.g., P-5: 35-36), and having ‗freedom of speech‘ (e.g., P-1: 126-127; P-8: 316-317; P-9: 542-546; P-15: 78-81; P-24:

259-260). In some cases, Western values were associated with drinking alcohol (P-1: 126; P-5:

44-46; P-8: 300-305; P-20: 248). In other words, while many Kuwaiti values were associated with adherence to traditional cultural norms, most Western values were associated with choice, freedom, or rebellion.

The Westernization I felt my clients face which I've seen comes with the way they

want to live their life, whether they want to date or not, whether they want to have

relationships before they settle, maybe they don't even want to get married.

Westernization in the sense of their tastes, their views on the world, umm, I think

the big portion of my clients if not the majority are critical of Kuwait. (P-1: 133-

137)

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Participants discussed conflicts between ‗Eastern‘ and ‗Western‘ values when describing intergenerational conflicts that largely revolved around the ability to choose. Therefore individuals who want to feel less ‗restricted‘ will turn to existing value systems that they perceive to be more conducive to their self-expression and that allow them to make choices. In effect, ―the younger generation is stuck between East and West‖ and ―a lot of people don‘t know who they are‖ (P-4: 1412-1414). More often than not, the desire for self-expression is attributed to being ―Western‖, and the Western world is perceived as having the ability to ―save‖ or ―rescue individuals who want to challenge tradition and overcome their depression and anxiety (e.g., P-

13: 287-289):

A lot of people I think that come here [to therapy] and they are feeling depressed

feel like the only way they are going to be happy is if they move out of Kuwait

rather than working on their perspective and you know how to cope with living in

their own country instead of this idea that, umm almost like this…Western

notion…you know how Westerners kind of have this notion that they are the

saviors? It has almost been like internalized, like ―if I just go to the West‖ haha

you know? …To America, everything will be better‖. (P-13: 282-289)

This tendency to ‗turn to the West‘ was illustrated further in Participant 18‘s story about how her daughter ―stole her passport‖ and fled Kuwait to live in a Western country (P-18: 265-

277). She also described Kuwait as going through the same social and feminist movements that took place in North America and how her daughters are epitomizing them by resisting traditional norms and expectations:

[I‘m] not saying that the West is bad, but they‘ve adopted so many things from

the West here, which is fine, within limits. But… My younger daughters are not

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strong in their religion, and do not dress conservatively anymore. When I bring it

up, they roll their eyes and they don‘t want to pray… This is happening all over

Kuwait and it is upsetting me. (P-18: 415-417; 506-509)

As a mother who converted to Islam and is vigilant about the reputation and therefore the welfare of her daughters, their resistance to tradition was upsetting to her and her family. In other cases, very traditional Arabs feel that they have been invaded by the West (e.g., P-8: 720-751; P-

20: 192-230). For instance, when I asked a non-Kuwaiti Arab man how he felt Kuwait changed after the Iraq invasion, he provided a very strong statement:

Kuwait, after the invasion is not the same Kuwait as before the invasion. Uhh and

Western power, it puts control on the entire region, and that by itself makes a

problem for everyone… So as one crisis ended, another crisis started... We know

that the Western powers did not just come to liberate Kuwait or make Kuwait

free. They came with their own invasion as well. And they came with a different

invasion – not only a military invasion, but they came with also their cultural

invasion, mentality invasion… A lot of things changed for people. Accepting the

Western culture. And you know what is the Western culture, how it is in general.

Maybe someone will hear what I‘m saying now and will start laughing at that, but

that‘s for us... That‘s really stressful. We don‘t like this [Western] culture. We

hate it. We hate our girls wearing these [overly provocative] types of clothes, we

hate that people like to drink, because for us – in our religion – it is prohibited…

What happened exactly for people by this cultural invasion happened by Western

men. (P-20: 192-230)

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The narratives of Participant 18 and Participant 20 demonstrate that there is a high degree of resentment towards the Western world among some members of the Kuwaiti community owing to vast generalizations. This tendency to generalize Western values was evident in several other interviews, including a Kuwaiti psychiatrist‘s:

We seem to be more relaxed than even people in the States… In the States I find

people (only) have work and drinking… They work, work, work, work, work, all

throughout the week, and then they just drink, drink during the weekends. I didn‘t

see much of family links between them. (P-8: 297-307)

Simultaneously, however, there is also a tendency to perceive the West as being more accepting of individual choices. For example, Participant 9 (514-517), while discussing ―first world stuff‖, made an important distinction between socio-political ―ideals‖ and socio-political

―reality‖. He felt that there are a ―homogenous set of values‖ that are now becoming global that individuals expect ―to be fitting into all these different pockets of [society]‖, such as ―everybody has the right to free speech‖, ―everybody‘s equal‖, ―fair trade‖, ―equal work for equal pay‖,

―when that‘s really not true‖. He laughed cynically, and said:

It‘s a part of the American constitution, but this ain‘t America… But you get

somebody, an American, making a stupid movie and putting it on YouTube…

And he‘s got freedom of speech, [but] it‘s highly offensive, over here on this side

of the world… Your values are not global, my values are not global… American

values are not global… They‘re American… It‘s just kind of first world stuff,

isn‘t it? (P-9: 546-558)

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When I asked how these values are realized in America, he said, ―we give it talk‖ but

―they‘re ideals‖ that are ―born on university campuses‖ which are ―artificial environments‖ (570-

572). Although only two participants, both of whom were healthcare providers (Participant 9 being a male therapist from North America and Participant 11 being a female physician from

Kuwait) , made the distinction between ideals and reality, many other participants‘ perceptions were similar in that they neither glorified nor criticized Kuwaiti or Western value systems.

Rather, they spoke about both cultures in very relative terms. These individuals also appeared to be more politically and culturally conscientious, which lead to the formation of the next two themes: in the first one (3.3), I look at how individuals culturally integrate in Kuwait, while in the second one (3.4) I focus specifically on how mental health professionals‘ ideological perspectives can impact their approach to providing care in Kuwait.

3.3. Finding value in Kuwaiti social norms enhances cultural integration in Kuwait

Many individuals – particularly women – had to find ways to adapt to Kuwait‘s cultural norms to avoid social exclusion, gain respect, or feel more culturally integrated. These methods of integration primarily involved overt behaviours as well as personal choices that allowed them to understand and appreciate some of the social norms in Kuwait that were conducive to wellbeing.

For instance, a non-Arab woman in her mid-twenties, who was born and raised in Kuwait, described her transition from being ―a wild thing‖ to being extremely conservative in her appearance and demeanor (P-5: 525-52; 140-142). She said, ―I‘m in this country, I have to make choices and sacrifices and maybe it is for the best‖ (138-139). She felt that she was unhappy doing ―whatever the hell [she] wanted to‖ in Kuwait (528). She was also unhappy being too conservative, and felt that finding ―the right balance‖ that wasn‘t ―too extreme‖ in appearance, demeanor, and behaviour was what she needed to do to enhance her feelings of integration,

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respect, as well as her personal and professional development (140-144; 156-160). Another personal choice that she made was studying and then converting to Islam (519-522), which she understood to be more community-oriented rather than oppressive:

When I first converted [to Islam], I felt complete. I felt whole and I felt.. I felt…

like I knew why… I can‘t wait for Ramadan. Because there‘s this—the whole

country changes. It may become a little lazy but there‘s more giving, there‘s more

love, there‘s more happiness and.. That‘s what I like about being Muslim. I feel

happier. I feel…I feel… more knowledgeable… People don‘t really understand

what Islam is especially—well not especially – but some Muslims as well and my

mom...and other Westerners. They understand that Islam is oppressive. But it‘s

not. It‘s completely the opposite. It‘s more about freedom and happiness and

finding love in—love of life! Love of what you do, love of yourself, love of

others. Or love for others (P-5: 525-572).

Participant 5 also felt that making these transitions allowed her to overcome her previous tendency to take her family and her overall wellbeing for granted (528-537). In other words, religion helped her find meaning in her family, community, and her overall wellbeing. Similarly, a female Kuwaiti physician who identifies as relatively conservative also felt that Kuwait – given its cultural emphasis on religion and rules – only suits ―a certain type of personality‖ (P-11: 456-

461). She felt that ―it is very useful to believe in God‖ in Kuwait and gave the example of coping with the death of a loved one; statements such as ‗it‘s meant to be‘ or ‗you‘re going to see this person after you die‘ are, for her, a ―fantastic explanation‖ that ―helps a lot of people cope‖; that

―whether it‘s true or not is not important‖ (P-12: 461-464). She further said that she will ‗choose‘ to be religious, because it ―contributes to [her] mental health‖ in Kuwait (465). Remaining

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cognizant of cultural norms also allows individuals in Kuwait to maintain their family‘s reputation and cultivate supportive relationships. For instance, Participant 2, a Kuwaiti mental health service user, felt that discussing her history of childhood sexual abuse and adult substance abuse publically in an attempt to de-stigmatize them would disrespect her family by potentially damaging their reputation. Respecting these cultural and familial boundaries, however, helped her avoid the loss of her ―credibility‖ (170) in her family and community and therefore maintain relationships that were important to her:

No matter where you are, I think that drug addicts have a hard time explaining to

people that they went through something and it was... they couldn't control it.

Because, no, no matter where you are, people still kind of don't understand that.

They just think ―drugs… why can't you control it?‖ …Like I know my family

wouldn't be comfortable with me [discussing my substance use publically]… I've

realized that... What I am going through also affects my family, and what I'm

talking about to the public. My family is very supportive, [so] the least I can do is

sort of, you know.. like, keep in mind how they feel about what I talk about

[publically]. (P-2: 172-181)

Other participants, including foreign therapists, also alluded to the fact that living in

Kuwait enhanced their appreciation of social cohesion. For example, when I asked a non-

Kuwaiti, Arab psychologist what brought her to Kuwait, she said:

[I had] unfinished emotional business with Kuwait…I‘m not done with Kuwait

yet… It‘s very personal for me, I have a lot of memories here... Culturally

speaking I like that people are pretty warm, they‘re relatively open to outsiders…

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They don‘t seem offended when you speak in a different Arabic accent… It‘s a

relatively warm culture, relatively welcoming. (P4: 113-116; 334-335; 340-344)

When I asked Participant 3 what he liked about Kuwait, he said he wanted his children to have the opportunity to ―be exposed to Kuwaiti culture‖, its ―emphasis on interpersonal relationships‖, and ―maintaining and sustaining relationships‖ (P-3: 73-76). He also reflected on his life in North America and how that helped him appreciate Kuwait more:

In North America, relationships are much more transient and they seem more

tenuous and almost temporary. But in Kuwait everything sort of centers around

interpersonal relationships and connections… I was raised to be much more of an

individual, I came from an individualistic family… So I see that the collectivism

and the strong family unit in Kuwait – I understand the appeal of that, the

importance of that. So with my own [family], I think things will be different. (P-3:

76-90)

Another male therapist who spent a large portion of his life in North America felt the same way:

The one thing I can take away from being here is… That I want to invest in my

family… [It] really influenced me as to how they continue to care for their family,

they continue to invest in them, they continue to… support them… There‘s a few

things that older men have said to me, that have really impacted me… I want to

adopt that value… I was thinking, you know, you live at home for twenty years

and then you‘re married and raise a family for twenty years and then you have

your own life for twenty years. But… I don‘t want to do that anymore. So this

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culture has influenced me to be a… a stronger family man, as an adult…As a

father... So I‘m thankful for that. I‘m really thankful (P-9: 1390-1402)

All participants who felt ‗connected‘ to Kuwaiti culture, regardless of their nationality, also appeared to be more culturally integrated. In other words, they did not demonstrate hostility towards either Western or Kuwaiti cultural norms. Rather, they discussed both cultures in relative terms and intentionally cultivated relationships with local Kuwaitis or made conscious decisions to find the right balance between ‗collectivistic‘ and ‗individualistic‘ lifestyles. On the other hand, some individuals – including Kuwaitis and non-Kuwaiti Arabs – had very negative views of either the West (as we saw earlier) or Kuwait. Although all participants were asked to discuss what they liked and disliked about Kuwait, it was what they disliked, and how they discussed their dislikes that became important in this analysis. The word ‗tribal‘, for instance, was mentioned several times while discussing Kuwaiti culture, however some participants associated tribalism with solidarity and support – e.g., ―your tribe will support you‖ (P-11,

Kuwaiti physician: 84). Another participant mentioned that individuals ―move in a strata where they‘re all connected, they‘re all tribal‖ (P-5, North American psychologist: 954). When I asked a Kuwaiti physician what she disliked about Kuwait, she took a strong stand against the discrimination that occurs between tribes:

[I don‘t like the] tribal and religious racism [bigotry]… As in, ‗you‘re from which

tribe?‘ And the thing that I hate most about Kuwait is the division of the social

classes… People who originate from, let‘s say, Iraq. Versus, people who originate

from Saudi Arabia… Some tribes are belittled.. Some tribes refuse marriages with

other tribes… Because of these differences. [I don‘t like] the humiliation that can

occur because of these differences (P-8: 216-230).

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Another Kuwaiti woman said something similar, but she discussed extreme tribalism with ignorance and oppression:

They used to bury girls alive, they had extreme tribalism, they were very

materialistic… Because the richer we look, the prettier we look, the better we

look, the reflection is better on our family. And that always stems from trying to

separate each other – that you‘re from that tribe, you‘re from that family, you

belong here, and we are here, so these are your set of characteristics. (P-21: 170-

186)

The examples above allude to two important points: first, ‗tribal‘ can be associated with connection and solidarity (Participants 11 and 7). Second, it can result in problematic, dualistic

‗us versus them‘ thinking, which can lead to discrimination, humiliation, and oppression of different tribes who do not, or cannot, uphold the same materialistic values as their own

(Participants 8 and 21). Participant 1 took this another step further and sharply contrasted ‗tribal‘ with ‗advanced‘. For example, she felt that ―there are so many aspects [about Kuwait] that are

Westernized‖ such as such as ―technology‖, ―urbanization‖ and ―people‘s lives advancing‖ – which is perceived as a good thing – ―but it‘s still the same Arabic, conservative, almost tribal mentality‖, which is perceived as a bad thing (P-1, Arab therapist: 138-139; 149-150). Similarly, when I asked a Kuwaiti psychiatrist about the factors related to mental health and illness in

Kuwait, he compared Kuwaiti tribes to aboriginal populations in the Western world:

Certain families they don‘t cross marriages, they marry within the same [family or

tribe]… So they spread of course the disease. And they spread the major

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symptoms [of mental illness]. Now this is a part of the culture. Of course it‘s not

happening in the UK or Australia, except maybe with the Aboriginals. And that‘s

why they have more problems – like the natives or aboriginals in Canada. They

have the same sort of illnesses – substance abuse, psychosis – because of inter-

marriages from the same tribe… They have the reserve and they marry and do

everything there. And at that reserve they have problems with their let us say uhh

psychiatric disorders (P-10, Kuwaiti psychiatrist: 238-247).

Participants 1 and 10 sharply contrasted tribes and families in Kuwait with typical

‗Western‘ societies. To them, tribalism was not only viewed as problematic, but also primitive or inhuman. Participant 10 felt that this cultural factor in Kuwait was the cause of psychiatric

‗diseases‘, including substance abuse and psychosis. Participant 1 also said, ―I don‘t like the sense of privilege [in Kuwait]‖; that she ―grew up in a very equal society [North America] and

Kuwait is not an equal society. Kuwait is a hierarchy‖. This essentialist – specifically, orientalist

– perspective, in which the West is associated with advancement, justice, virtue, and socioeconomic equality, while Kuwait is perceived as unequal, uncivilized, and ignorant, can be common among individuals who engage in what Participant 9 called ―Kuwaiti bashing‖:

In a lot of expat circles it‘s not long when you‘re Kuwaiti bashing and I-I really

try to stay away from that. It feels icky to me and I don‘t like that. And I-I stopped

it a long time ago… Just complaining about the place, or the people, or you know,

―here‘s a story about a dumb Kuwaiti‖ you know, what they did, or what they

said, or… [sarcastically] ‗hahaha‘. So it‘s just in expat circles (P-9, North

American therapist: 1373-1384).

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Although Participant 9 felt that ‗Kuwaiti bashing‘ occurs only among expatriates, it was also evident in interviews with other Arabs and Kuwaitis themselves. As Participant 26 said, many Kuwaitis ―identify with more or less Caucasian white Western culture‖ and that they ―sort of look up to people like what they could have been‖ (P-26, former psychiatric patient: 133-135).

This was also reflected in the finding that individuals who had a more orientalist perspective towards Kuwaiti culture were also those who glorified the West and found relatively little meaning in Kuwait‘s cultural norms. The next theme explores how the ideological perspectives discussed thus far can impact mental health professionals‘ approaches to care.

3.4. Mental health professionals‟ underlying ideological perspectives were related to their perceptions of mental health, mental illness, and mental health services.

With the exception of one Psychiatrist (Participant 10), who I did not explore the definitions of health, mental health, and mental illness with owing to time constraints, all the clinicians initially felt that health and mental health were achieved through ‗subjective wellbeing‘ rather than an absence of illness or psychopathology. To them, wellbeing included physical, emotional, social and spiritual health. In this way, all participants viewed health more holistically; one physician even quoted the World Health Organization‘s definition of health in his interview, which fell in line with what everyone else said (P-19: 108-111). Some professionals also made the point that regardless of culture or upbringing, ―humans are the same… They are all the same‖ (P-19: 87-

89) because ―people are people‖ and ―the process of grieving no matter what words you give it is the same‖ (P-7: 720-721). Similarly, Participant 9 said:

Our relationship needs are the same no matter what country we‘re from; we still

have all the basic needs of um… you know, the need to be heard, the need to be

loved… the need to be chosen, the need to feel safe, the need to feel touched, the

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need to feel like you belong. All these are basic needs no matter what country we

come from. (P-9: 182-185)

Although clinicians‘ perceptions of health and illness were initially very similar, I started noticing stark differences in their ideological perspectives that were not apparent in the early stages of their interviews. These ideological perspectives were evident within two predominant narratives. The first consisted of statements that were persistently community-oriented and client-centered, while the second type of narrative was more inconsistent, contradictory, contained more individualistic or disease-oriented perspectives, and sometimes discriminatory language.

Five out of the eleven clinicians discussed both Western and Kuwaiti cultures in relative rather than absolute terms (e.g., P-3: 424-444; P-4: 252-263; P-6: 250-252; P-9: 468-480; P-13:

785-787; 1100-1101). They also did not glorify the Western world, nor did they demonstrate any orientalist (i.e., anti-Arab) perspectives. These therapists also placed more importance on multiculturalism and finding ways to build rapport with service users. Additionally, they were more critical of the notion of individual psychopathology and psychiatric nosology and focused instead on the protective cultural factors that can promote mental health in Kuwait (such as family support and religion), and problematic environmental factors that can lead to what looks like a mental disorder. These factors were related to inequality, authoritarianism, oppression and abuse – all of which can manifest within the family environment (e.g., P-3: 328-330; P-4: 1509-

1525; P-9: 409-419; P-13: 634-638). Although these therapists differed in their gender, nationality, years of professional experience, and location of postgraduate training, they had three factors in common: first, they had backgrounds in social work, feminist theory,

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multicultural counseling (e.g., working with immigrant populations), and/or community development (such as working with high risk or special needs youth). Second, they received no formal training in medicine. Third (and ironically) they were all in private practice in Kuwait, and primarily saw clients from the higher ends of the socioeconomic scale.

Participant 4, a non-Kuwaiti Arab psychologist, said that she was interested in ―how people are shaped – identity wise – by their home culture‖ or ―what they perceive to be their home culture‖ as well as ―multiculturalism in general‖ (70-71). Participant 3 (North American), while discussing his educational background, said that he found mainstream psychology ―too experimental‖; that he was more interested in ―the environment rather than individual psychopathology‖ because it made room for ―multiculturalism‖ (13-17). These therapists were also firm in their belief that their ―connection with a client‖ (P-4: 962), where their client is their

―sole focus‖ (P-3: 186-187), is imperative for good therapy: ―if I can‘t connect [with my client],

I‘d fire myself‖ (P-4: 969-972). They also described approaches that decreased the power differential between themselves and their clients (e.g., P-4: 2136-2146). For instance, Participant

9 felt that clients could not fully express themselves unless they cultivated a strong, trusting relationship with their therapist; he reflected on a scenario where his client finally demonstrated a lot of anger towards him: ―that takes a lot of trust. It means trust is happening‖ because ―he‘s not bluffing now… He‘s showing me his anger‖ and ―he feels safe enough to say what he thinks‖

(P-9, North American therapist: 878-894). For these therapists cultivating a trusting relationship was necessary in helping their clients recognize their own resilience. As one female Kuwaiti therapist said,

People can improve just by me giving them genuine care and understanding…

How healing that can be once a week and I see the changes in people… It‘s that

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connection, it‘s the connection that‘s number one… [They] can feel more

motivated in their own life and feel more empowered just by me reflecting back to

them the things that they don‘t see in themselves [such as] their strength and

resilience. (P-13: 480-491)

In short, these therapists were more client-centered, used a more interpersonal approach to providing mental health care, and tended to focus on their clients‘ resilience rather than psychopathology. They were also quick to point out the difficulty in using the DSM to diagnose mental illnesses (e.g., P-6: 215-217; P-13: 345-374). Participant 3, for instance, felt that Axis II

(personality) disorders appear to be more prevalent in Kuwait, but also questioned whether

―there are cultural differences in the ways that emotions are expressed and relationships

[develop]‖; that ―I don‘t necessarily think the categories of symptoms are particularly helpful in

Kuwait‖ (P-3: 424-444). Similarly, Participant 9 felt that the DSM is helpful for understanding

‗symptoms‘, but not for classifying ‗illnesses‘ (1472-1473). Participant 4 asserted, ―take everything with a grain of salt, and then customize‖ because ―the semantic component is huge in the Arab world‖ (1549-1551). She also took a very critical stand against the DSM:

It‘s a lot trickier for us to define mental illness… Because to me, a lot of illnesses

like, for example, in the DSM…A lot of those are arbitrary. That was a bunch of

older, white, Caucasian, ‗Waspy‘ [White Ango-Saxon Protestant] – identified

males getting together… Sitting around in a conference room at a table,

discussing their cases. And, even though it says the ‗Diagnostic Statistical Manual

of Mental Disorders‘… It‘s not based on statistics at all. It‘s based on what they

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think – what this particular group thinks…So it‘s very subjective (P-4, Arab

therapist: 604-620).

Participant 4, who identifies as a feminist, also asserted that classifying illnesses ―should not be in the hands of one person or one group, ‗cause that gets dangerous‖. She felt that there are ―a lot of narcissistic, power-hungry people out there who like control‖ and ―who want the rest of the world to believe that certain qualities are a pathology‖; ultimately, she felt that psychiatric nosology allows individuals to ―point the finger at certain people and say, ‗hey, something is wrong with you. Go get fixed‘‖ (P-4: 659-670). Similarly, a Muslim therapist also consistently took a stand against the notion of psychological ‗abnormality‘ and felt that it was counterproductive to mental health, particularly among young children who are very difficult to diagnose (P-6: 453-462). Nonetheless, these clinicians‘ interviews resonated with Participant 4‘s argument that there are some instances where a ―diagnosis would be warranted‖ but that people cannot be ―diagnosed in a vacuum‖; instead, ―they need to be diagnosed within a context… A socioeconomic, and linguistic context‖ (P-4: 1506-1513). Finally, none of these therapists were hypercritical of the psychiatric services in Kuwait, and they showed no biases towards their own therapeutic modalities; rather, they opted for more integrated forms of care.

In contrast to the narratives above, some interviews were fraught with inconsistencies in how clinicians spoke about culture, mental health and mental illness, regardless of their gender, nationality, years of professional experience, or whether they worked in public or private practice. Some of these professionals were more likely to pathologize cultural differences.

Although their narratives made it difficult to understand why this occurs, Participant 4 had a plausible theory:

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Pathologizing [cultural] differences… I think, personally, that comes from the

practitioner doing that to themselves… Because of if you pathologize yourself

because of some cultural difference or something that you‘ve adopted from

Eastern culture that doesn‘t fit with your Western culture, or vice versa, you‘re

more likely to pathologize others. (P-4: 1203-1209)

Two of these clinicians were very reflexive and honest about how they consistently struggle with their cultural, religious, or educational biases and how these impact their interpretations of morality, mental health and illness, and their approach to providing care (e.g.,

P-7, Psychologist: 777-817; 1003-1028; P-8, Psychiatrist: 532-615). These clinicians, similar to some clinicians mentioned above (e.g., P-4: 1790-1811; 1203-1211; P-9: 291-308), felt that reflexivity is a strong, parallel process in their caregiving practices. Participant 8, for example, openly admitted that she thinks homosexuality is wrong, because her religion, Islam, ―comes before psychology and psychiatry‖:

Here‘s where you get stuck between normal and abnormal versus right and

wrong… I cannot say it‘s abnormal to be a lesbian or gay… But I can say it‘s

wrong [because] I cannot detach from my religion… [Homosexuality] is illegal

[in Kuwait]… But you still have to separate them… Your own beliefs are

different from that of the patient… I try to remain neutral [and] whenever the

client asks me for my beliefs… I state it clear that ―it is your life… It is you,

who‘s going to live, so, what‘s more important is your own beliefs, not mine…

I‘m here to help you develop [through] your struggle – to not feel guilty‖… If

somehow we [clinicians] feel uncomfortable… We‘re trained to not judge [but] it

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takes time, and it‘s not easy… At the very beginning it was very stressful. (P-8:

543-610)

What Participant 8 demonstrated here was high degree of honesty and commitment to understanding her bias against homosexuality during therapy, to the extent that when we explored the notion of morality – in an Islamic context – later in the interview, she began to see how homosexuality is not a criminal act (e.g., relative to homicide or sexual violence) and should not be perceived as one. Additionally, although she felt that she needed to ‗digest‘ our discussion on morality, she acknowledged that providing care and support for her homosexual or bisexual patients does not mean that she is turning her back on Islam (and sinning), as she initially feared (P-8: 912-917; 937-

1208).

On the flip side, Participant 7, from North America, said that her cultural assumptions and biases were directly impacting how she ―heard‖ her Kuwaiti clients (777-778). To circumvent this, she had to cultivate professional relationships with local Kuwaitis to ―save‖ her

―from a lot of serious errors‖ and help her develop more culturally appropriate methods of communication (784-789). She felt that the real cultural bias she had to understand was related to her ―Western linear thinking process‖ when her and her clients set goals during therapy: ―I just think in terms of 1-2-3-4-5‖ which was ―impacting the therapeutic process‖ since her Kuwaiti clients generally have to consider how each of their family members would respond to any of their lifestyle changes. Her whole interview was bursting with statements such as these: ―my cultural assumptions‖ (756); ―my cultural bias‖ (778); that the notion of ‗time‘ is a ―real cultural bias‖ (770), and ―the biggest issue I‘ve had with cultural bias… Comes from being individualistic‖ and ―assuming my client has that same process or that same capacity‖ (829-830).

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She compared her clients‘ ―capacities‖ in terms of ―my culture‖, ―my training‖ and ―my sort of infrastructure‖ (1003-1005). She later turned this around and criticized that same linear thinking process when she said that certain personalities may seem ―manic to a straight-laced, linear thinking Westerner‖, which she felt is a ―huge problem‖ in Kuwait (1192-1193). In short, these statements continuously came up in the interview to the point that she was beginning to sound overly vigilant about her biases. Although Participant 7 was highly insightful and informative (in fact, it was one of the most lengthy and rewarding interviews I conducted) – her narrative illustrated how difficult it can be for even the most reflexive of psychologists to ‗shake off‘ the notion that a mental illness is an individual phenomenon. This was most apparent when she compared two of her clients who were both given a diagnosis of schizophrenia:

I had two umm… Two different clients, both with a diagnosis of schizophrenia,

and one had essentially decided that schizophrenia was not going to keep her from

doing… the things that she wanted to do… She worked really hard to learn the

symptoms, to learn how to manage her medication… Pulling all the components

together to live the quality of life that she wanted. I worked with another man who

had a diagnosis of schizophrenia and he just wanted to lay down and die… For

him that was just a diagnosis that he didn‘t think he could overcome and he was

just condemned to a life of an invalid. And it – it is totally individual… She was

out doing things, and he was turning – literally turning – into an invalid. Every

twitch that he got was the result of the medication that he got, he was getting

tardive dyskinesia, you know, he was a wreck! And he was absolutely convinced

that his life was over because he had a diagnosis of schizophrenia… He literally

just collapsed in on himself, and it showed physically. So the whole recipe of

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quality of life has to include you know, your physical health and psychological

and emotional equilibrium, and your cognitive processes. (P-7: 397-415)

What Participant 7 did here was initially blame her male client for 1) not having the same outcome and quality of life as her female client, and 2) experiencing side-effects from his medication. While her male client went down a trajectory of being an ―invalid‖ owing to his faulty ―cognitive processes‖, her female client was perceived as resourceful and cognitively healthy. When I probed about her clients‘ family and social environments, she said that both clients had ―very different social circles. In his particular case, his family saw him as sick‖, however her female client ―hadn‘t even told the family‖ (P-7: 423-424). Nonetheless, her first explanation of her clients‘ very different responses to a diagnosis of schizophrenia was based on individual differences in cognition, without noting the importance of their families‘ responses (or lack thereof). Her narrative resonated with Participant 1‘s perception that mental illness – or at the very least, a poor quality of life – occurs because of ‗internal‘ factors:

Most disorders come from one of those – the way you think, the way you feel, the

way you act. Mood disorders come from the way you feel or not feel or whatever,

certain mental disorders, like anxiety or depression mood disorder or certain other

disorders come from the way you think. Schizophrenia, Psychopathy, umm....

Borderline is a mix between the way you think, feel, and act. (P-1: 258-262)

In other words, this textbook perspective of ‗maladaptive‘ thoughts, feelings, or behaviours essentially forces physicians (and therefore service users) to look internally, rather than externally, to find the source of their anguish. This tendency to ‗blame the individual‘ – or in many cases, to blame Kuwaiti ‗culture‘ – was shared by a few clinicians in this study

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(including local physicians, as we will see below). They all differed in their nationality and years of professional experience. Even when biases were noted, they spoke about culture in more absolute terms – particularly if they glamorized the Western world and were hypercritical of the non-Western world (e.g., P-1: 138-139; 149-150; P-7: 706-709; 673-685; P-10: 238-247). For example, Participant 7, while discussing how some of her clients complain about psychological issues – e.g., ―I think I‘m going crazy‖ (685) – while they actually have noticeable medical issues, felt that the non-Western world is ignorant of ‗basic health‘ knowledge, while the

Western world is more enlightened. She attributed this to the lack of public health advertisements in non-Western world – which she felt should include psychiatric disorders. Here, we can see how she criticizes Kuwait and the non-Western world in general, on strong moral grounds, for not understanding what she believes to be ―basic health‖ facts:

There‘s a level – and I want to use the word appalling – level of ignorance here

about basic health issues. Because there‘s no generalized public education that‘s a

part of T.V. commercials – you know, like we get in North America!! We still get

commercials there and public service announcements that are required, by law,

that it is entrenched in telecommunication systems that a certain number of

minutes, every day, has to be dedicated to public service announcements… So

you get these cycling ones about anxiety, and depression, and bipolar, and

ADHD… What are the symptoms of depression, you know.. And basic health

things, right?? And there‘s none of that here, and I‘ll say something to someone,

and it‘s totally new information to them! They just don’t have – and it‘s not just

Kuwaitis, it‘s basically any non-Western ummm individual, client, often has no

idea of basic health things. (P-7: 674-684)

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This tendency to moralize the propagation of psychological knowledge was shared by several other clinicians, who also demonstrated a stronger desire to prove the discipline as worthy of honor, respect, and compliance in Kuwait. For instance, even though Participant 10 was adamant that social workers and psychotherapists are crucial to an effective healthcare system (P-10: 150-151; 219-220), he also felt that physicians such as OB/GYNs, surgeons, and those working in emergency all need to rely on psychiatrists, and vice versa: ―we need them, and they need us‖ because if a woman is depressed during her pregnancy, ―you need one‖; if a woman has post-partum psychosis in a maternity ward, ―you need immediate psychiatry‖; and if a child has ―anorexia nervosa and is dying‖ in a medical ward, ―you need a psychiatrist‖ because

―this is the logical way to do it‖ (P-10: 253-259). He felt that psychiatrists need to ―beg‖ executive hospital staff to allow outpatient psychiatric services: ―they are our colleagues when we were in medical school‖, however, because psychiatry is ―not welcomed‖, they are faced with the response, ―go away, we don‘t like you‖ (P-10: 259-268). In other words, resistance to mental healthcare, here, is almost discussed as a professional, as well as personal, betrayal. Similarly,

Participant 1 partly blamed the poor prognosis of mental illness on people‘s tendency to rely on sources other than mental health services for support:

[There is] a lot more severity in the conditions here… Because people wait longer

to seek help. Because of the culture, because of the reliance on religion, reliance

on family, reliance on the family doctor.. Anything but the psychologist. And

when they do finally come to us they're pretty much deep into their problems or

into their diagnosis (P-1: 619-623).

Although Participant 1 was not alone in this perception, as we will see below, she also partly attributed the lack of faith in mental health services to the confidentiality breaches by

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some clinicians in Kuwait: ―there‘s no confidentiality when it comes [to] certain psychiatrists…

Not all of them‖ because they ―discuss clients at Dewaniyas [male social gatherings], discussing names‖. Though she made a valid point, her narrative alludes to two important assumptions. The first is that relying on religion, family, and family physicians rather than mental health professionals for mental health issues is wrong. The second assumption is that the lack of ethical service delivery is a major barrier to seeking services in Kuwait. In other words, it is assumed that mental health professionals are more capable of providing care for people experiencing psychological distress, and that enforcing confidential service delivery is the only way to elicit widespread trust and compliance in mental health services. Participant 1‘s statements, ―anything

[anyone] but the psychologist‖ and ―how are they going to believe in us?‖ highlight the strong, and almost dramatic desire to prove psychology as more efficacious in the eyes of the local community.

Overall, the interviews of Participants 1, 7, and 10 suggest that some mental health professionals might be more interested in reinforcing the agency of their profession in Kuwait than they are in empowering the local community. The interviews I conducted with physicians who were primarily trained in Kuwait paint a similar picture; however, they do this in a very different context and demonstrate far more social cohesion with the local community.

Unfortunately, their interviews also suggest that indigenous definitions of health and practices of care are beginning to wane in Kuwait.

3.5. Medical discourse is actively transforming indigenous perceptions of mental health, illness, and caregiving practices in Kuwait.

The following passages explore the ways in which medical discourse can actively distort indigenous forms of care provided by local physicians. The two Kuwaiti family physicians, who

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were both trained in Kuwait (and briefly in Europe), felt that they had to learn how to provide psychotherapy, or at the very least, ‗talk‘ to their patients openly because at least half, if not most, of their patients‘ physical complaints ‗correlate‘ with ‗psychological‘ or ‗psychosocial‘ factors (e.g., P-14: 26-28; P-19: 7). I analyzed their narratives together because neither of them were certified to provide psychotherapy, yet they were very in-tune with the needs of Kuwaitis

(including Bedouins, or seminomadic Kuwaiti tribes), Bidoons (stateless illegal immigrants from neighbouring Arab countries), as well as foreigners who were on the lower rungs of the socioeconomic spectrum. In fact, these two family physicians, along with Participant 8, a

Kuwaiti psychiatrist, became very important in my analysis because 1) none of them were trained in, or lived in North America unlike most of the other clinicians I interviewed, 2) their first language was Arabic, 3) they had a greater understanding of Kuwaiti and religious values, and, most importantly, 4) they all worked in the public setting and provided both medical and mental health care for patients from all stratums of Kuwaiti society on a regular basis.

In their interviews, Participants 8 and 14 protested against the fact that they were not taught about the ‗mind-body link‘ in medical school: ―they didn‘t tell us about mental health issues… They separate the body and the mind‖ (P-14: 1215-1217). Participant 14 admitted that she ―didn‘t understand the links between endocrinology and psychiatry… How the thyroid affects anxiety, and how depression affects diabetes‖; she learned this ―after ten years of working

[in Kuwait], not ten years of schooling‖ (P-14: 1219-1223). Participant 8 also expressed her frustration with the medical model: ―what‘s the point in having diabetes controlled and people taking aspirin after a stroke‖ if patients ―are not living [their lives]?‖ (P-8: 42-43). Participant 19 also felt that the training for family practitioners in mental healthcare is ―inadequate‖ (693); that

―it is difficult to highlight what‘s normal from what‘s not normal‖ in terms of mental health and

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illness; however, ―the main thing for me is that [my patients] are socializing, loving, going to work‖ and have no ―physical aspect of their mental health condition‖ (154-156).

As family physicians, Participants 14 and 19 feel that their work is not merely ‗clinical‘; they generally provide social support for individuals going through difficult life events, such as familial or work conflicts, that interfere with their physical health and daily living. In some cases, Participant 14 sees issues (e.g., depression and anxiety stemming from abuse) repeating in families from one generation to the next and intervenes by increasing her patients‘ awareness of the effects of abuse on their family‘s overall health (329-341). This is done by following up with their patients regularly – sometimes both and out of the clinical setting – and on a long-term basis (e.g., P-14: 352-355; P-19: 182-190). Much of this support is provided to mitigate current illnesses and as a pre-emptive strategy to prevent future illnesses among their patients:

I‘m one of them… I am with them for various events, like deaths for example. If

there‘s a death, I go with them and give them my condolences. They have any

wedding party, they‘ll invite me. So I am there all the time with them. In their

school, I am there. I am part of the people in the area… The family physician

knows the people… And [we] see the changes in their life events and the changes

over the years... We can see the illness at its early stages… So that is why we are

in the preventative state [of care] to prevent mental illness (P-14: 274-297).

Being actively engaged within the same community as their patients was also described as beneficial by Participant 8, who was frustrated at her boss for forcing her to terminate therapy with a patient owing to a ―dual relationship‖. She attributed this to her boss being trained in

North America and not truly understanding Kuwaiti culture:

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There‘s always going to be some sort of connection like, their [the patient‘s]

children are with the children of your sister in the same school… They know your

neighbour… Somehow in one way or another, you‘ll connect to them… How can

I avoid that? …But I was forced to terminate therapy [with some of my clients]…

I‘m Kuwaiti, but [my boss] has been in Kuwaiti for…Not as long as I‘ve been in

Kuwait. And… uh, he wants to apply [the North American] code of ethics as is to

my clients… I get instructed to act in a certain way, which I totally believe is…

not beneficial for my clients…And the problem is that the doctors, the other

doctors who [have] the power – have been trained [in North America]. But we’re

the ones staying in the emergency rooms, we’re the ones being all over the place

[so our] opinion…Should be taken into consideration… More than those who

have been trained outside Kuwait… How can they know our patients‘ needs,

demands, weaknesses, and strengths if they don‘t know our culture? (P-8: 719-

820)

Participant 8‘s narrative is a classic example of how cultural conflicts can impact the organizational structure of mental healthcare in Kuwait and distort existing practices of care.

This is further evident in that the physicians‘ theories and practices of care sometimes conflicted with each other. For instance, Participant 8‘s notion of a caring society was one in which

―everyone should have the right to… contribute to the development of [Kuwait]‖ and ―everyone should have the right to speak… Express their opinion‖ and ―have their dignity preserved‖

(2138-2141). She also felt that religion does not endorse discrimination (P-8: 216-217).

However, she also said the following:

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In our religion, if you support a sinful act… Then you are sinful too… You cannot

support uhm, whoever is doing something religiously unacceptable.

Homosexuality in our religion, is unacceptable… In [my mental health practice],

what if I end up supporting someone doing what I believe is sinful? …It‘s an

Arab fact… If you support something sinful… You, yourself, are sinful (P-8: 913-

931).

Participant 8 admitted that she is still conflicted between her understanding of her religion and her role as a healthcare provider. She also felt that that mental illness is more likely to occur when individuals go ―against the norms in our society‖ and engage in behaviours that deviate from these standards, such as substance use and being homosexual or bisexual (443-444).

In other words, she feels that being mentally healthy means ―doing what is expected by you, by your society… for your age, gender, and more‖ (416-417). Later, however, she felt that ―laws are needed to protect women since they have less freedom than men‖ (1677-1687). She was also angered by the fact that she has less freedom to provide meaningful input in her work environment (876-881), thereby resisting the idea that individuals must act within the confines of what is expected of them. In other words, she said that societal factors shape wellbeing.

However, while discussing substance use, she said it‘s ―the nature of the disease itself, like being manic‖ which results in a ―lack of insight‖ (1352-1357), thereby taking the same medicalized view of the individual that she critiqued very early in her interview (42-43).

While all three physicians attributed poor mental health to societal factors, they also shared the global language of medicine. This resulted in a peculiar tendency to initially attribute mental health issues to societal factors, but then inadvertently blame the individual for poor mental health outcomes. Particularly in Participant 14‘s case, we can see how being more

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communitarian and attempting to see all patients holistically, or ―in a three-dimensional way‖, is transformed by the use of medical language which forces her to biologically manage patients by enforcing ―compliance‖ (e.g., P-14: 27-35; 612) even though this is not well received by many of her patients. For example, Participant 14 was frustrated by the fact that many of her Kuwaiti patients who are diagnosed with schizophrenia do not respond well to their medication and are hesitant to continue treatment:

They will not accept treating [their] schizophrenic… son, or daughter. They will

not accept it at all. And even if we force them to take the medication, the side-

effects of the medication [are] annoying them, you know? …For example, being

sleepy all the time, or gaining weight sometimes, or slurred speech from the anti-

psychotic medication, spasms... Once they see this – the beginning of these side

effects they will be very hesitant to continue the medication… That‘s why they‘re

getting worse… And it‘s not psychiatric, it‘s a mental health issue. (P-13: 654-

663; 1265)

Despite the statement, ―it‘s not psychiatric, by the way… It‘s a mental health issue‖ (P-

14: 1230-1231) we can clearly see medical discourse in action here. The fact that service users and their families can be annoyed by negative side-effects of psychiatric drugs is perceived as a burden, and relying on alternative forms of care is seen as a barrier to the acceptance of psychopharmacotherapy. This can occur to the extent that a physician can ―force‖ patients into compliance and transfer blame to the patient and their families for worsening symptom severity.

Similarly, Participant 19 – though less rigid in his perceptions of psychopharmacotherapy – also illustrated how medical discourse can begin to replace religious discourse. In an attempt to reach out to the religious community in Kuwait, Participant 19 said,

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That‘s why I went to the mosque. I talk to people… To explain and to tell them

about even simple depression or, um, sometimes OCD. You tell the patient…

There is a cure, God said that you should, uh, take care of yourself, and not harm

yourself. It is about religion. (P-19: 513-517)

The use of religion to justify the use of mental health services occurs on moral grounds, and the aspirations are noble; however, this narrative highlights one of the ways in which psychiatric nosology is perpetuated in the local lexicon. Another way is through the media, according to Participant 14: ―now we can see in Kuwaiti series, the obsessive compulsive, the paranoids‖ that demonstrate ―you‘ll improve your functioning, your married life, if you see the psychiatrist or counselor or psychotherapist‖. Although it is not well received publicly,

Participant 14 hopes that ―maybe our kids will grow up on this message and change this idea‖

(965-974). This shift – i.e., replacing ‗God‘ with ‗medicine‘ – is also beginning to occur within more rural areas of Kuwait, where alternative (i.e., external) explanations of mental illness, such as Jinn (demons) and evil eyes are more prominent (P-14: 517-522). For instance, Participant 14 said some of her patients feel that ―the evil eyes of other people‖ can have negative effects on them and cause depression, to which her response was, that ―makes no sense‖; however, ―after taking a course of antidepressants these ideas disappear‖. She then tells them, ―where are those envious eyes now?‖ causing ―their thoughts [to] change after the treatments‖ (P-19: 513-516).

Participant 19 felt that externalizing blame – i.e., blaming God for testing individuals during life‘s struggles, and solving issues as a family instead of seeking outside help – occur owing to these ―wrong beliefs‖ (P-14: 74-76).

Finally, although not currently a mental health provider, a young Kuwaiti woman who is presently pursuing a career in clinical psychology was angered by the fact that the Kuwait

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Ministry of Higher Education ―lumps‖ Psychology with the humanities, and would rather it be categorized, or at least viewed in the same light as Medicine: ―rather than sociology and anthropology… I would lump [psychology] with health‖ (124-126). To her, ―not only does that show that they don‘t understand that there are many disciplines of psychology‖, but it also shows that there is a lot of ―institutional stigma‖ and ―lack of awareness of psychology‖ (126-131). The fact that she feels that psychology is separate from anthropology and sociology, while also claiming that higher education in psychology is needed for social activism in Kuwait is bizarre, and demonstrates that there is a drive to convince the Kuwait Ministry of Higher Education – who rightfully cluster psychology, anthropology and sociology under the same domain – to view psychology in the same light as medicine to make it more worthy of public recognition and respect.

The second metatheme sheds light on the complex interaction between cultural values and the perceptions of mental health, illness, and mental health service delivery in Kuwait. The interviews suggest that perceptions about morality – which are largely defined by religion and culture – shape social interactions, subjective wellbeing and caregiving practices in Kuwait.

Additionally, mental health discourse is beginning to shape primary care practices; now, instead of prescribing painkillers or blood pressure medication, family physicians are introducing

‗mental health‘ to their practice by offering psychotherapy and, more often than not, liberally prescribing antidepressants, antipsychotics, and other mood stabilizers to their patients. Many times, as demonstrated above, psychiatric drugs are imposed on patients, even when they refuse to take them.

The themes above illustrate that Kuwait is currently experiencing very rapid sociological changes in that it borrows from the West while at the same time resists it. Simultaneously, many

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individuals are blaming Western culture for the younger generations‘ increasing libertarian perspectives. All of these are directly impacting wellbeing in Kuwait – particularly among the middle and upper class who are more likely to have their voices heard. Additionally, they explain how global (i.e., American) medical discourses are actively transforming local Arab meaning systems related to mental health and illness.

4. Methods of resistance are often misunderstood by mental health professionals in Kuwait

This metatheme explains how resistance to oppression and inequality can be manifested, misunderstood, and often silenced in Kuwait – including by the mental health industry. This includes an exploration of the different faces of stigma towards mental illness; i.e., how it is experienced, defined, and how we can distinguish it from resistance (4.1). Likewise resistance is explored within the context of mental healthcare; this includes a description of how resistance to authority – in a culture where most forms of resistance are punishable – manifests and is expressed in Kuwait. In other words, I tease apart the methods by which individuals – primarily mental health service users – both overtly and covertly resist oppression (4.2 and 4.3). Finally, I explain how Kuwait may currently be on the brink of social reform (4.4).

4.1. Resistance to mental healthcare is often recast as stigma

All resistance to mental healthcare is often attributed to a lack of awareness, understanding, negative personal experiences with mental healthcare, and, most importantly, stigma (e.g., P-1: 216-223; P-2: 307-312; P-3: 538-547; P-21: 53-56; P-23: 289-293). Stigma was generally described as a negative perception towards an individual or their family for utilizing mental health services. Clinicians and the mental health discipline at large were also described as being stigmatized because of the widespread perception that those who pursue careers in mental healthcare are going to ―ruin their reputation‖ and become ―crazy doctors‖ (P-

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21: 53-56). Stigma was also defined as the avoidance of mental health services in fear of becoming a social outcast (e.g., P-4: 1890-1905; P-7: 912-918). Those who seek mental health services do so in strict secrecy, because of the shame associated with seeking mental healthcare, and the fear of being labeled as ‗crazy‘ (P-1: 10; P-2: 293; P-14: 572-576). To feel ‗stigmatized‘, therefore, is to feel shame and live in isolation. Finally, stigma was said to have profound negative impacts on individuals with mental health issues because the shame, secrecy, and isolation that come with it often worsen symptom severity. Participant 7, for instance, recounted an extreme case of how stigma can be dangerous:

I had a family show up here, wanting to know what to do, because they had a 19-

year old boy patrolling in their house with a loaded AK-47 because somebody

was coming to get him…. And he‘s not connected to reality! Clearly thought that

some members of the family were a threat? They were not going to call the police,

and they had no intention of taking him to the psych ward. Does that increase

mental illness? Yes! Does that increase the chance that somebody is going to die,

or get shot, or hurt? Yes! (P-7: 926-942).

Where a teenager gets a loaded AK-47 in Kuwait aside, this case demonstrates that some families will wait till their relative‘s behaviour becomes too out-of-control before seeking help owing to the fear of being stigmatized. Another reason for refusing to seek mental health services is negative personal experiences with the mental health sector. For instance, one therapist reported that his client‘s previous therapist tried to play ‗matchmaker‘ between her and a different client: ―[her] previous therapist tried to get them…to get married, because their other client was lonely and wanted to get married‖ (P-3: 538-544). Another client reported that a

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female therapist told her husband, ―you need to put a leash on your wife‖ during couple‘s counseling to ―restrain her‖; the therapist added, ―how can you let her be so expressive and run the show?‖ (P-6: 1263-1269). She scoffed at the oppressive language by many therapists in

Kuwait, and said that when ―whack-jobs‖ are allowed to work as psychologists, clients have

―more traumatic experiences‖ (P-6: 1242-1252). Much of the oppressive language within the therapeutic setting was directed towards women who disregarded traditional gender norms.

While stigma, shame, secrecy and negative personal experiences all contribute to a lack of trust in mental health services in Kuwait, there is less recognition of actual resistance to psychological and psychiatric services. For instance, Participant 7 quoted a parent who responded negatively to her son‘s diagnosis: ―don’t you tell my son he has ADHD!‖ (P-7: 961) after he received a diagnosis too abruptly. Although this therapist attributed this to stigma, other participants noted that while ―Americanized‖ clients are more accepting of a diagnosis (e.g., P-4:

769-774), more traditional Arabs do not like being labeled with Western mental disease categories and would rather forgo care altogether. Participant 14 also noted that many of her patients do not believe in the ―efficacy of psychotherapy‖ and have ―no patience to see the results‖ (191-194). These examples suggest that many Kuwaitis are actively resisting modern mental healthcare, rather than fearing stigmatization per se (e.g., P-4: 761-765; P-7: 914-916).

Participant 20‘s statements, that ―Western powers [exert] control on the entire region‖ and that

―they came with their cultural invasion‖ and ―mentality invasion‖ (192-230) also indicate that the desire to transform Kuwait to fit North American values is met with resistance and contempt among some traditional Arabs. This is also entrenched within the governmental sector since it refuses to invest time and money in awareness campaigns through television and radio

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advertising (P-4:799-803), however it appears that this may begin to change owing to recent anti- stigma and mental health awareness campaigns.

4.2. Resistance to authority is recast as deviance or diagnosed as a mental disorder.

As mentioned earlier, Kuwait has a large population of foreign domestic workers who experience major human rights violations. In most cases, they would rather stay in abusive situations than go back to their home countries, either because they experience more violence in their home countries, or they need the money to support themselves and their families. Therefore, most of these cases go unreported. Many times, when questioned, domestic workers – particularly women – will report that they were in an ‗accident‘ when in fact they were abused. Participant 26 summarized this very common scenario:

I‘m sure you know that this happens a lot here, the pushing slash falling… If you

check the Kuwait or Arab times, it will be like, ‗maid falls from window‘ and

they‘ll never tell you what kind of fall it was and there are a lot of cases where

people chuck them out the window. Uh, so, actually when we went to the

hospitals so many people would be like, ―yeah, I fell from the window, I fell from

the window‖ when in fact they were pushed. (P-26: 269-273)

In the event that a female domestic worker reports a rape, she‘s generally held liable:

―yes, the rape victims, the abuse victims, uh, generally go to jail‖. Sometimes, if they try to escape from the house, they are pushed out of the window. This is ―automatically filed as a suicide case or attempted suicide which is illegal in Kuwait‖ therefore many women ―go to jail for being raped‖ (P-26: 299-301). Participant 26 advocates for these women since him and his wife were also involved in rescuing many of them who experienced physical and sexual

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violence. On the other hand, Participant 8, a female psychiatrist, had a very different perception about foreign domestic workers in Kuwait – particularly African women:

The presence of the Ethiopians in Kuwait…for the past 10 years, Kuwait started

to, uh- accept… African domestic helpers… For some reason, I don‘t know

why…they had a lot of documented crimes and killing… They‘re bring them to

our hospital- we have two wards that are filled with Ethiopians… We cannot

understand their behaviour because of the language barrier. And they killed…like

there was an incidence where a helper killed the bride… and when she was

interviewed, she‘s- she stated that- that it‘s out of jealousy- she killed her with a

knife. There was another incidence where… uhm, another Ethiopian lady had a

child‘s neck completely cut… Africans do have this very violent behaviour… in

the wards they‘re very- they‘re very violent with the rest of us. (P-8: 1571-1599)

Being a victim of physical or sexual violence does not necessarily justify killing anyone, especially a child, however, this is an extreme example of what can happen when women – especially African women who have most likely witnessed or survived even more horrific experiences in their home countries – resist oppression. If they are not killed and have their bodies dumped in the desert (e.g., P-26: 344-346), they become institutionalized – either in prison, or in an inpatient psychiatric ward. Here, they are diagnosed with schizophrenia or psychosis and given heavy doses of antipsychotics to subdue their violent behavior. As a male psychiatrist said while attempting to rationalize the use of psychiatry for deviant or violent individuals, ―psychiatry equals violence. It is known everywhere in the world. Psychiatry means violence because they become violent‖ (P-10: 488-490).

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As a less extreme example, Participant 12 recounted her experiences with the mental health sector in Kuwait. She said she was put off by one of her psychiatrists when he said she was a ―very jealous person‖ and ―very vindictive‖ in front of her parents because she feared that her partner was having an affair (P-12: 1131). After ‗acting out‘ and being ‗deviant‘, she was told to answer a multiple choice questionnaire to determine her diagnosis:

They made me take this test first, to… see where… which category I fell into…

The test was multiple choice, it was like… Certain situation like, what would you

do, and then you have the answers… like, A, B, C, or D, and it took like, an hour,

maybe an hour and a half to do. Yeah, so I took the written test, and then they

gave me a letter that said ―she is type… whatever paranoid schizophrenia‖ this is

what she has, like, they gave me a written paper. (P-12: 1294-1308)

Many participants felt that ‗normal‘ behaviour is often pathologized – particularly for women – in Kuwait. For instance, Participant 7 felt that what a Western psychologist or psychiatrist may diagnose as mania ―is actually really not that much different than the dramatic norm‖, however ―it‘s overwhelming, or seems manic‖ to many Western clinicians (1190-1192).

Participant 4 had similar thoughts:

I think borderline would be over diagnosed here… Arab countries that are more

expressive with emotion, we‘re louder, we‘re more colourful… Which I think is-

is beautiful. I love it, it works for me. I‘m talkative. I‘m loud. I love it… To

someone who‘s not familiar with the culture or who is familiar with the culture or

even comes from the culture and doesn‘t like that aspect they can pathologize it.

And view it as… label, or overly expressive… That sometimes goes with

borderline. Sensitivity… is uh- is something that happens, people are- are

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sometimes offended by certain things, people might not be as flexible as you want

on certain things. And that‘s fine. Because people can do whatever they want to

do, they should be free to be flexible or not flexible…. Sometimes that‘s

pathologized (P-4: 1472-1493).

In some cases, it can be very difficult to determine whether a set of behaviours point to resistance or to a mental health issue. For example, another physician recounted a case where a man, who I also later interviewed, came into her clinic, complaining that his wife was ―behaving in a weird way‖ since she refused to wear her hijab. Initially, the clinician felt that this was a classic case of ―a woman rebelling against oppression‖ because ―she took it [the hijab] off her head, threw it on the floor, and stomped on it‖. Her husband, however, said that ―she actually loves being a Muslim, and she believes in the hijab‖ therefore this was ―abnormal behaviour for her‖. The physician admitted that ―it is not easy to evaluate a person like that because she‘s from such a different world than I am‖ therefore ―I don‘t know what is normal, and what is oppression for her‖. Since her behaviour became more erratic and unpredictable, she was given a diagnosis of recurring ―acute psychotic episodes‖ and is now on anti-psychotic medication. Her husband feels that she‘s happier, and back to her normal, compliant, God-fearing self again (P-12: 388-

416; 422-425; P-20: 744; 889-890).

4.3. Fear of punishment or social exclusion impedes overt resistance to oppression in

Kuwait and can result in different expressions of mental health issues.

In addition to resistance to mental health services, many participants – particularly mental health service users – demonstrated other forms of resistance. For instance, Participant 2, who identifies as a bisexual, spoke up about homosexuality during a psychology lecture at a local university when her professor said ―you can change homosexuals‖ (577-581), after which she was kicked

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out of her class. Therefore, Participant 2 found ways to circumvent being punished by discussing mental disorders in more socially acceptable ways. Since it was culturally unacceptable for her to talk openly about being raped and her history of substance abuse, she decided to instead talk publicly about her eating disorder as a way to bring together other men and women who had similar experiences (140-143). This allowed her to access a community of individuals who not only had eating disorders, but also struggled with issues pertaining to abuse, substance use, and homosexuality (438-460). In this way, cultivating resistance against the beliefs, attitudes and behaviours that are unacceptable in Kuwait also involves an understanding of Kuwaiti social norms so individuals can circumvent them and enhance solidarity between individuals who live similar experiences.

Many participants also felt that living a double life is very common in Kuwait. Since getting a divorce, being homosexual or an atheist, ‗partying‘, or choosing your own marriage partner have negative social consequences in Kuwait, many individuals resist these norms by living lives that they keep hidden from their families (e.g., P-1: 356-365; 687-699; P-3: 385-389;

P-7: 1119-1125; P-9: 477-478). Many clinicians felt that most, if not all, of their clients or patients were living a double life in Kuwait. This included men, women, and adolescents who would otherwise be rejected by their communities for following different standards from what are considered to be traditional Kuwaiti cultural norms. Some aspects of living a double life include women and girls who are torn between being ―daddy‘s good daughter‖ or the ―party chick‖ (P-9: 1068-1069); ―partying like mad‖ over the weekends while ―wearing a hijab and going to school‖ on weekdays and ―going on a trip to New York or Cyprus to have their hymens restored before marriage‖ (P-7: 1135-1139). One therapist felt that ―these dichotomies can become like an addition‖, or an ―escape from reality‖ into ―a secret life of isolation, affairs,

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additions, or alcoholism‖ to the extent that many people – especially men – will have ―secret apartments‖ and ―secret relationships‖ (P-9: 1068-1075).

Having a double life is almost widely expected in Kuwait, therefore individuals in

Kuwait were generally described as very vigilant about who they open up to, and skilled at lying on the spot to the point of becoming pathological liars. Although some people consider this to be an individual dysfunction since it makes people ―fake‖ or ―shallow‖ (e.g., P-1: 167-180; 357-

358), it appears that it is the only way that individuals can resist cultural norms without leaving

Kuwait. However, living a double life can cause additional mental health issues:

It‘s like secret keeping. Living a double life, and consistently maintaining a

double life, has the same impact on an individual as an adult or adolescent who is

keeping secrets like sexual abuse or a grave family dysfunction, where their

minds are literally split in two: the part that can be public and the part that has to

be protected. And they develop common behaviours… They often manifest these

behaviours. They‘re very secretive, they‘re very closed off, they answer questions

with questions, you know… They‘re very cautious about what they say… Like

the longer they do it, the more likely I am to find out that they just simply lie

about everything. (P-7: 1141-1152)

The ―identity turmoil‖ caused by living in ―these different worlds‖ is thought of as necessary, and inescapable – not only to protect an individual‘s reputation – but also to protect their family‘s reputation. ―In the West it‘s a little more easy to be open about tragedy and loss and failure‖ since ―it‘s an individual failure, rather than the shame of the family‖ if you ―lost your job, or that your marriage fell apart‖, therefore many individuals will live double lives ―to protect the family‘s honour‖ (P-9: 1079-1083). One element of family honour in Kuwait is

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upholding Islamic values. One therapist narrated what a male client, who was both atheist and homosexual, said to her during his session:

The truth is, I can actually be gay here it‘s not difficult to be gay here. I can‘t

walk down the street holding my girlfriend‘s hand, but I can walk down the street

holding my partner‘s [boyfriend‘s] hand. Not a problem… My family knows I‘m

gay and they‘ve finally accepted that I‘m not going to get married… They‘re not

happy about it, but they‘re fine with it. [But] if my father caught even a whiff of

the fact that I was an atheist, that I have eschewed Islam, and I am a committed

atheist, I think he might actually consider killing me (P-7: 1051-1061).

Given that Kuwait has a reputation of being highly collectivistic, where family is supposed to be the most integral component of an individual‘s life, people can feel more disconnected from their family members than they do in the West since they can‘t be ―authentic‖ with them (P-3: 385-389; P-14: 513-528). In some cases (such as the one above) the social pressure to appear religious can be so high that it is more important than keeping your sexual identity a secret. Rather than recasting the behaviours that come with living a double life as a pathology, however, they are portrayed here as methods of resistance. Therefore, resistance, here, is seen as the development or adoption of a set of cultural or political beliefs and the cultivation of certain habits or behaviours that stand against the social difficulties that individuals face.

4.4. Kuwait may be on the brink of social reform.

Many participants described events that suggest Kuwait is experiencing a gradual shift from conservative to more liberal values. In particular, resistance that is seen within the family environment (e.g., towards authoritative parents) is now beginning to shift towards the public 249

domain (e.g., publically speaking and acting against inequality). Participant 9 felt that this shift is

―born on university campuses‖ in Kuwait much like they are in the Western world; that students are beginning to talk openly about ―fair trade‖ and ―equal work for equal pay‖ (557-577).

Participant 18 further compared this shift to the feminist movement in the North America:

It‘s just like the revolution in the States when women – and the flappers did all

these funny things – all of this is happening now. We‘re in the midst of this

change. I‘m struggling with my youngest wearing a hijab but then wearing skin-

tight leggings. Because it doesn‘t go. You can‘t cover yourself and then have

skin-tight legs stickin‘ out… (P-18: 506-509)

Some Kuwaiti women are also beginning to talk more openly about how ‗ignorant‘ many customs and traditions are in Kuwait and discussed the pitfalls of extreme religiosity and materialism. The women who spoke against injustice were those who sought knowledge in the social sciences and were highly educated. For instance, Participant 21, a Kuwaiti woman in her mid-twenties, provided a historical explanation and critique of Kuwait‘s conservative culture:

I really think when they used to call the age before the prophet came, ‗The Age of

Ignorance‘, I truly believe that the Arab customs and traditions are very, very

ignorant. And I think a lot of the influences, or a lot of the negative influences on

our culture right now, are from those lasting customs and traditions that were

passed on for many generations in the Arab culture… And that‘s why there‘s a

high emphasis on materialism… Around the 80‘s they started this new wave of

religiosity, and I think it had sort of reached a pinnacle in the work like a lot of

people – women started wearing hijabs after the war? And obviously threats of

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war and threats of disaster tend to do that to people. (P-21: 170-174; 182-183;

191-194)

A female Kuwaiti physician also spoke against the racism that is embedded within the healthcare system in Kuwait: ―I don‘t think they give [foreign workers] the same respect they deserve‖ and that medical administrators and key stakeholders are ―racist in some ways‖ against

―darker people or coloured people‖ who are also ―poorer‖ (P-11: 109-111). She said that the

Kuwait Ministry of Health is currently attempting to enforce nationality-based segregation in hospitals since foreign domestic workers are ―clogging the hospitals‖. Her Kuwaiti friend told her, ―this is really ridiculous, we can‘t go to the hospital, they are all lined up before us‖, to which she responded ―go early! Get in a slot!‖ (147-149). Many Kuwaitis were angered by the

‗first come first serve‘ policy at the public hospitals since they received health services after some foreign workers – even though Kuwaitis arrived later. Therefore, the Ministry of Health passed a new policy, where Kuwaitis get the first fifteen slots at any public hospital, and foreigners‘ first possible option is the sixteenth slot. So even if a foreign worker arrives earlier, they have to wait until Kuwaitis receive services before being able to see a doctor (149-152). She got angry during the interview and said, ―who‘s building your house, who‘s doing the plumbing?!? Are they any less?!?‖ because ―you are not getting off your ass to work‖ (152-154).

Participant 11 also said that many Kuwaitis rationalize segregated healthcare because they do not receive equal health services in foreign countries: ―yes they do [segregate us]! When we go to Switzerland, we are not treated as equal citizens‖ to which she responded, ―but you‘re going as a tourist. You‘re not a resident of their country, you‘re not an employee‖ unlike the foreign workers in Kuwait, and exclaimed that their logic is ―bullshit‖ (155-158). Participant 11 then described how her and a number of physicians – primarily Kuwaiti women – publicly stood

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against the Ministry of Health administrators – who are primarily Kuwaiti men – to stop the new legislation that is currently on the table:

I was a part of the group that fought… The Private Insurance Hospitals, they‘re

called. Their goal was to build three hospitals, only for expats… Never heard of

this kind of rubbish before, but this is – we fought [in collaboration] with the

Kuwait Human Rights Society to stop this project. So it is stopped [for now], but I

don‘t know where this is going. There is so much drive to create this… I‘ve never

seen anywhere in the world where you separate people in healthcare. It doesn‘t

make any sense. So the fact that some people think this and debate it… It‘s

something that disturbs me… What category are you now going to classify the

expats? To upper level expat, middle level expat, lower level expat? Like what are

we doing here? So… A lot of people don‘t see that the way they speak about this

issue is an issue… I‘m talking about people who are educated, in my

surroundings… People who you know, go to Switzerland every summer haha. So

they think it‘s normal. They think, ―hmm this is not racist, not sexist‖, so it‘s

okay. So this is something that I find extremely frustrating. (P-11: 122-143)

I had a private discussion with another physician, who asked not to be recorded and to remain anonymous, who said that some of the women who spoke against the Ministry of Health were female pediatricians, OB/GYNs and gynecologists who politely reminded the men who are trying to pass this law that they have their wives‘, sisters‘ and daughters‘ pregnancies in their hands, effectively threatening to go on strike, or voluntarily withdraw their services in the

Ministry of Health. As it stands right now, many hospitals are being built in Kuwait, and this legislation is still on the table and being debated. The fact public authority figures and other

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Kuwaiti citizens are beginning to compete for power in an attempt to negotiate the meaning of human rights demonstrates that Kuwait is beginning to experience social movements intended to enforce social justice. This is occurring through solidarity between individuals who have similar humanitarian aspirations and is mostly initiated by students in higher education. In addition to fighting for foreign workers‘ rights, medical students are beginning to challenge the Kuwait legal system on the current lack of regard for children‘s rights:

People are moving in the right direction, in that people are beginning to move in

the Child‘s Rights Society, which was started by medical students and is an active

association, society in Kuwait, working to have laws implemented. You know,

they‘re active, and they‘re slowly making progress. And there‘s big names

involved with that, so you know, it‘s coming… (P-7: 657-660)

Other narratives also demonstrate how Kuwait is currently experiencing social reform.

Participant 21, for instance, fought against the Ministry of Higher Education in an attempt to fund higher education in the social sciences in humanities to the same degree they fund the natural sciences: ―we started making appeals – multiple appeals to the scholarship committee to get funded‖ (72-73). She was angered by the fact that the Kuwait ministry funds students who receive ―Cs and Ds‖ with scholarships in business and the natural sciences, ―but they wouldn‘t give an A student who wants to go into Psychology a scholarship‖ (75-76). Considering that speaking against authority figures, especially as a woman, was almost unheard of in the past, these actions suggest that many young adults are beginning to act more progressively in Kuwait.

Social reform is also beginning to take place with regards to topics on sexual orientation since many homosexuals and bisexuals in Kuwait are beginning to ―come out‖ to their families,

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after receiving support from their community and other resources (e.g., some mental health centers) that are quietly beginning to gain more social momentum (e.g., P-2: 389-390; P-7: 1093-

1098). This is occurring despite a lot of discrimination against homosexuality (e.g., P-1: 691-

697; P-8: 534-548; P-13: 537-549; P-14:1099-1100). For instance, a psychologist attempted to publish ―a newspaper article about the queer community‖ in Kuwait by discussing ―the differences in orientation‖ with the goal of ―normalizing‖ various sexual orientations which was

―revoked by the very big newspaper here‖ (P-1: 691-694). However, open discussions about sexual orientation are beginning to increase in Kuwait, especially among the queer community, who are currently still ―very much underground‖, but nonetheless very active (P-1: 696-697):

―because when you start talking, that‘s when awareness happens, that‘s when you‘re fighting against oppression‖, for ―gay rights‖ and ―the queer community‖ (P-1: 695-697). One participant, who identifies are bisexual said that she finally mustered the courage to come out to her mother, who has now accepted her sexual orientation (P-2: 389-390). One therapist also said that one of her male clients openly told his parents that he‘s gay: ―they‘ve finally accepted that

I‘m not going to get married… They‘re not happy about it, but they‘re fine with it‖. The fact that

―his partner was actually living in his apartment in the family room‖, to her, was ―very progressive‖ for Kuwait (P-7: 1093-1098).

Members of different races and social classes are coming together to fight against human rights violations in Kuwait. Some of this activism is beginning within the mental healthcare system, however it is also occurring among foreign workers. For instance, a male south-Asian psychiatric patient discussed his involvement with a few independent social activist groups such as the Kuwait Human Rights Society among others (which he left anonymous). He said,

―Western members of the group and the few Kuwaiti members‖ are ―able to do so much more

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towards human rights than we [non-Western foreigners] are‖ in that ―they can walk into a place and say, ‗what‘s going on here? Explain this to me‘‖, however, ―as an Indian or a South Asian or a Filipino, they will not speak to you or they won‘t even look at you‖ (P-26: 147-151). However, by coming together with ‗powerful‘ Kuwaitis or Westerners, non-Western expats are given more voice. Even though Participant 26 could not discuss his perspectives on the harsh treatment towards foreign workers in Kuwait, he began publishing writings online which caught international recognition:

The Human Rights Watch caught wind of what I was writing on the blog and

that‘s what kind of got them to send representatives to Kuwait and sort of survey

the situation with the maids, like, the deportation centers and things like that and

then that started this whole thing about Kuwait is like, uh, it‘s like, denying

human rights to, you know, the people that need it the most here. So, that sort of

moved things a little bit along in the world recognizing that this region has a

problem with that. So, most of what I did, personally, was just writing. You know,

because I can‘t get too involved [publically]. (P-26: 252-258)

After discussing these events with Participant 26, I had a conversation with a personal contact at the Indian Embassy (who asked to remain anonymous and to not be recorded) who said that the outcomes of the Human Rights Watch involvement in Kuwait lead to a series of investigations by the Indian Embassy in Kuwait, after which domestic workers began reporting high rates of physical and sexual violence, particularly from their Kuwaiti ‗sponsors‘. The Indian

Embassy has now officially banned Indian foreign workers – particularly women – from entering

Kuwait owing to these allegations, in an attempt to protect them. Some domestic workers, like

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we saw earlier, are even beginning to become violent towards abusive sponsors, demonstrating that some foreign domestic workers are beginning to disrupt the current status quo in Kuwait.

This metatheme used participants‘ narratives to explain the differences between stigma and resistance, with an emphasis on what resistance looks like in Kuwait. Additionally, it shed light on the fact that public discourses for women‘s, children‘s, the LGB community‘s and foreign domestic workers‘ rights in Kuwait are beginning to take place. These all suggest that social reform is occurring in Kuwait. Ironically, even though much of this resistance is occurring within the health and mental health sector, many mental health professionals are unaware of the differences between stigma and resistance, let alone how some of their patients‘ behaviours are acts of resistance rather than acts of social deviance or psychological pathologies.

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Chapter VII. Discussion: Marketing Mental Illness in Kuwait? A Critical Analysis of

Global Medical Discourse in Action

The main goal of this study was to understand the lived experiences of mental health and illness in Kuwait from the perspectives of mental health professionals, mental health service users, and members of Kuwaiti community. Twenty-six in-depth, semi-structured interviews were conducted with participants from these demographics in Kuwait, and analysed using interpretive phenomenological analysis and critical discourse analysis. As discussed in Chapter IV, and supporting previous findings, the lack of mental health legislation is a serious concern among people in Kuwait since it prevents ethical service delivery (Al-Qimlass, 2015; Almazeedi &

Alsuwaidan, 2014; Scull et al., 2014). However, most evaluative studies tend to focus on service users and the types of services provided, rather than exploring the narratives of those who actually provide these services. Therefore one goal of the current study was to focus on the perspectives of clinicians in Kuwait at a time when mental health advocacy is growing and help fill this gap in the literature.

The interviews shed light on the perceptions about Western and global mental health diagnostic tools in Kuwait as well as an examination of how a clinician‘s academic and professional background can affect their interactions with mental health service users. It also highlighted some of the historical and socioeconomic drivers of mental health and illness in

Kuwait. Since many clinicians practiced in North America or other countries before they moved to Kuwait, they were asked more in-depth questions about how mental health and illness are similar and/or different across cultures. This lead to a richer understanding of some of the changes that would be necessary to improve mental health service delivery in Kuwait.

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The first section of this chapter sets the scene by discussing how and why Kuwaiti culture, society, and therefore any attempts to understand and diagnose psychopathology in

Kuwait are complicated. The second section focuses on the issues that young adults are facing in the wake of modernization; namely, that of adopting more ‗liberal‘ or ‗Western‘ worldviews that conflict with the traditional value systems of older generation Kuwaitis, and how this impacts wellbeing. The second section sheds light on how Kuwait‘s (arguably) neoliberal and autocratic models of government negatively affect women, children, nomadic groups, and low-income foreign workers. This is followed by a discussion on how Kuwait‘s current mental health principles and practices – which are beginning to follow the same trajectory as those of North

America – may be indirectly silencing the resistance of these oppressed groups in Kuwait, and causing more harm than good (e.g., by perpetuating iatrogenic drug dependence). The third and final section discusses several policies and practices that can save the Kuwaiti mental health sector from being a platform for ‗disease mongering‘ to instead being a vehicle for resistance, agency, and care for oppressed populations.

Kuwait: a Cultural Paradox

Kuwait was described as family oriented, collectivistic and socially cohesive, which supports previous findings (e.g., Scull et al., 2014). Some individuals also expressed contempt towards the underlying emphasis on materialism, reputation, and elitism – otherwise known as the

‗bourgeois‘ characteristics of any given society (Day, Rickett, & Woolhouse, 2014; Inglehart,

1971, p. 991-992) – that place the ‗well-to-do‘ (Kuwaiti, Western, and foreign upper-class) as worthy of honour, while the working class (primarily low-income foreign workers) are systemically positioned as the ‗other‘, whose needs are easily negligible. Some people also described Kuwait as extremely religious; however some people – including Kuwaitis themselves

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– felt that many Kuwaitis, particularly young adults, don‘t follow the teachings of Islam and pretend to be religious to maintain their reputations which support preliminary findings in a previous exploratory study (Scull et al., 2014). Kuwait also politically identifies with being

‗democratic‘ (e.g., Elbadawi & Kubursi, 2014; ―The Constitution of the State of Kuwait‖, 2014), and one physician felt that women have a lot of power in Kuwait (e.g., P-14: 1047), however the participants generally felt that Kuwait is more patriarchal since many women are treated as

―second class citizens‖ (P-4: 393). Discussions about Kuwait‘s political climate were highly skewed towards it being oppressive which echoes the literature during the last four decades (e.g.,

Ghabra, 2014; Herb, 2005; Ingelhart, 1988; Rizzo, 2005); that Kuwait, like Saudi Arabia, is highly authoritarian and will likely remain so for a long time because ―neither their social structures nor their political cultures seem favourable to democracy‖ (Ingelhart, 1988). Similarly,

Hudson (1991) predicted that the gulf crisis would impede the liberalization and democratization of the Middle East and that authoritarianism would be a leading feature of Middle Eastern politics. He also felt that ‗Arab democracy‘ is an oxymoron: a perception that carries forward today and resonates with the criticisms against the America‘s political agendas. For instance, the

Friedman (1962/2002) economic agenda of neoliberalism and the justification for war are both ironically framed within the contexts of ―liberty‖, ―freedom‖ and ―democracy‖ (e.g., Klein,

2007; Watters, 2010).

Finally, Kuwait was described as being highly ‗charitable‘ towards those who are less fortunate (e.g., P-17: 394-398) and that those who embrace Kuwaiti culture are very ‗warm‘ and

‗welcoming‘, (P-14: 340-344). However, Kuwait was also described as one of the worst places to live if you don‘t have ‗wasta‘, or clout, owing to the racism and human rights violations that permeate every social and political sphere of the country (P-3: 93-97; P-26: 23-24; 85-88; 344).

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All these starkly opposing narratives demonstrate that Kuwait‘s reputation, as well as its cultural and political identities are extreme and highly conflicted. Interestingly, this resonates with some of the more extreme perceptions of mental health service users in Kuwait: as extremely conflicted, dual-natured, lacking in transparency – i.e., ―borderline‖, ―maladjusted‖, ―living a double life‖, or disproportionately prone to ―psychosis‖.

Westernization or Modernization? Understanding Dialectical Change and Mental Illness in

Kuwait.

A perception that came up in several interviews was that Kuwait is a ―land of opportunity‖ – particularly for those who are more ―Western educated‖ and financially or socially ―privileged‖

(e.g., P-1: 155-161). This mimics the perceptions of the U.S. in the post-World War II or ‗baby boom‘ period, while America experienced an economic upsurge. During this period, baby boomers took part in civil rights movements and faced a lot of resistance from conservative groups for wanting to challenge America‘s racial status quo (Cherry, 2009; Heywood & Drake,

2004). The collective narrative of the participants in this study suggests that the current economic, political, and cultural climate in Kuwait is starting to follow a very similar trajectory.

We saw in the previous chapter that the term ‗Westernization‘ has two separate meanings in Kuwait. The first is associated with modernization – i.e., technological advancement, urbanization, higher education, and opportunity, which are regarded more positively. On the other hand, older and/or more traditional Arabs also felt that the ‗Western invasion‘ is negatively transforming the Kuwaiti population – particularly young Kuwaiti women – who are now speaking less Arabic, dressing more liberally (e.g., by refusing to wear the hijab), abandoning religious practices, socializing with the opposite sex before marriage, and drinking alcohol.

These findings broadly resonate with conservative reactions to the baby boomers who emerged

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adulthood in the 1960s and 1970s – who were now experimenting with drugs, practicing ‗free love‘, and participating in civil rights movements (Heywood & Drake, 2004): ―all of this is happening now. We‘re in the midst of this change. I‘m struggling with my youngest [daughter] wearing a hijab‖ (P-18: 506-509).

More specifically, these events echo Hassan‘s (2002) argument that the greatest challenge to the Muslim world is that modernity is characterized in two different ways: first, as the advancement of technology, and second, as Westernization – or the mass-adoption of liberal attitudes and ―deviant‖ behaviour. In other words, Western modernization is seen as desirable, while Western culturalization is equally, if not more, undesirable. According to Riffat Hassan, who is known in the academic world as an ‗Islamic feminist‘, modernized Muslim women in

Kuwait are generally seen as a symbol of Westernization, and blamed for being susceptible to

Western consumer culture by conservative thinkers (Cahill, 1997; Hassan, 2002). On the other hand, modernized Muslim men are seen as a symbol of progress and virtue. In other words, the

‗modern woman‘ is a violation of the social barrier which places women in the ‗private space‘ and men in the ‗public space‘ (Hassan, 2002). It was perceptions like these in America that propelled public feminist discourse and civil rights movements (Heywood & Drake, 2004). This inspires hope that social movements in Kuwait will eventually gain momentum.

Ghabra (1997) addressed other challenges that Kuwait faces and took a different spin on

Kuwait‘s autocratic governance. He felt that the United States‘ liberation of Kuwait pushed

Kuwait towards authoritarianism as a way to counteract the growing Westernization, which supposedly influenced younger generations to adopt more ‗liberal‘ attitudes associated with freedom and choice. However, the desire to choose is not ‗Western‘, but a preeminent threat to a tradition in which an individual‘s life trajectory is more or less chosen for them – one that they

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are expected to adapt to with the guidance of their elders. For instance, Participant 20 asserted that ―Western powers did not just come to liberate Kuwait‖; they also ―came with their cultural invasion‖ and a ―mentality invasion‖ in that ―Western men‖ (emphasis added) have negatively influenced traditional Arab women by making them more ―liberal‖ (192-230). His narrative highlights the opposition to Western culture among some traditional Arabs, and the perception that America has colonized Kuwait – a perception that is not uncommon in the academic world either. For instance, and echoing Klein‘s (2007) arguments, Hassan (2012) also argued that

America‘s ‗freedom agenda‘ in the Middle East is more reflective of American domination and colonization rather than the pursuit of ‗democracy‘. Cultural narratives such as these appear to be prompting many individuals to ‗shelter‘ the girls and women in their families, because they don‘t want to ‗open their eyes‘ (P-14: 1200) to the ideologies of an Americanized (i.e., modernized) world.

Some critical psychologists would argue that modernity brings about its own sense of fragility and uncertainty, thereby diminishing traditional thinkers‘ sense of coherence, or meaning prescribed to more traditional roles (McCubbin, 2009). For example, rather than viewing Participant 20‘s narrative against ‗Western men‘ as ‗xenophobic‘, which generally has a very negative connotation, it appears that he felt his traditional role as an Arab-Muslim man – who is expected to protect a woman‘s ‗integrity‘ – is being threatened and undermined. As

Antonovsky (1986) and Frankyl (1959/2006) surmised (while studying holocaust survivors), tradition is capable of bringing about a sense of meaning and coherence (opposed to a sense of nihilism and anomie) and is thus conducive to feelings of control and predictability – or what

Inglehart, Mansoor and Tessler (2006) would refer to as ‗existential security‘ – within a social organization. However, when any subjective feelings of control or predictability are threatened

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within a social organization – particularly within a dominance hierarchy – the end result is invariably a resistance towards the forces that are causing these changes (McCubbin, 2009;

Sapolsky, 2005). Inglehart et al (2006) would argue that this ‗existential insecurity‘ can contribute to some of the ‗xenophobia‘ and ‗in-group solidarity‘ that is seen among some Arab-

Muslims as well as all populations who have experienced major threats to their survival by a different ethnic group. Likewise – particularly after the events of 9/11 – Edward Said would argue that existential insecurity breeds much of the orientalism, or anti-Arab perspectives that many non-Arabs have towards people from the Middle East (Said, 1979). A classic example in the data was the ―Kuwaiti-bashing‖ (i.e., mocking) that a North American therapist discussed among some Western and other foreign groups in Kuwait, which he later said made him feel uneasy, or ―icky‖.

As we saw in the previous chapter, attempts at ‗sheltering‘ young women from the influence of modern life and ‗Western culture‘ can provoke them to run away from home or engage in risky behaviour. One clinician, who identifies as Christian, described many young

Kuwaiti girls as having unprotected ―sodomy‖ (i.e., anal sex), or what some call ―teenager sex‖ as a way to avoid having to get their hymens restored before marriage. ―When they‘re not doing hash, they‘re [drinking] alcohol [and] they‘re sexually promiscuous‖. She went on to say, ―the majority of the girls [I see in therapy] that have been sexual, it‘s all sodomy‖ and ―it‘s happening at the chalet [and] parties in basements [with] drugs and alcohol‖ (P-7: 1128-1123). In addition to having regular unprotected sex (which could also be owing to the lack of sex education in schools in Kuwait), some girls have been known to engage in more serious self-harming behaviours as a possible method of resistance against authoritarian parenting and also to ‗cry for help‘. The most serious self-harming behaviour discussed was multiple suicide attempts that land

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many adolescents in the emergency room or the psychiatric ward, where they can generally walk away with a diagnosis of a mental disorder and a prescription for mood stabilizers since some parents refuse to allow medical staff to hospitalize them (e.g., P-14: 1190-1200).

Results also point to other mechanisms by which Kuwait‘s political and economic climates impact social relations and therefore mental health in Kuwait. According to Inglehart

(1997; 2000), as economic development, industrialization and technological innovation rise in any country we can expect that younger generations who feel that traditional values are imposed on them will strive for self-expression, sexual freedom and autonomy more strongly than in countries that are less economically developed or societies that are more rural. There are several factors that can contribute to this ideological shift. One is that younger generations are likely to be more educated than their parents‘ or grandparents‘ generations were, which appears to be true in Kuwait (e.g., P-3: 394-407). Some research suggests higher education can foster more liberal political views and therefore supports this theory (Brandt & Crawford, 2016; Carl, 2014; Hodson

& Busseri, 2012; Schoon, Cheng, Gale, Batty, & Deary, 2010). Others suggest that younger generations who already have many of their basic needs met are less ―materialistic‖, or preoccupied by the necessity to make a living or run a house, and are therefore more likely to cultivate or merely adopt values that associate personal growth with feelings of individuality and autonomy rather than material wealth (Inglehart, 1997; 2008). In other words, generations who grew up feeling that ‗survival is precarious‘ are more likely to hold traditional values, while those who grew up feeling that ‗survival can be taken for granted‘ are more likely to hold non- traditional values (Inglehart, 2008, p. 131). Evolutionarily speaking, this makes sense: when our survival is threatened, we are more likely to value social codes that prescribe the acquisition of resources and reproduction.

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Additionally, modern technology and mass-media and being exposed to Western cultural ideologies (e.g., ‗freedom of expression‘) can make individuals feel more constricted in a society that does not publically embrace such ideologies (e.g., P-9: 514-558; P-13: 282-289), resulting an existential crises where individuals are ―stuck between East and West‖ and ―don‘t know who they are‖ (P-4: 1412-1414). Although research to specifically support this claim in the Middle

East is scant, Sam and Berry (2010) suggest that cultural integration (embracing different cultures simultaneously) may be more conducive to psychological wellbeing than acculturation

(being rigidly oriented towards one culture) or marginalization (embracing no cultural value system). Sam and Berry‘s (2010) definition of being culturally ‗marginalized‘ resembles the philosophical position of nihilism, in which neither value systems are viewed as particularly meaningful or useful – i.e., both systems are rejected (MacAskill, 2013). Previous research shows that nihilistic perspectives – which are likely to occur among those who consistently feel subordinated – are detrimental to wellbeing to the extent that they can contribute to psychosis

(e.g., Selten & Cantor-Graae, 2005) and self-harm (e.g., Brown, 2003). This may also be attributed to Emil Durkheim‘s notion of anomie, the feeling of disconnect from both value systems, and the feeling that one is merely ―floating‖ (e.g., P-3: 335) through life without a sense of purpose: a phenomenon most seen in societies that experience rapid social change (Swader &

Kosals, 2013).

Given that so many factors have been studied in order to better understand cultural and ideological shifts in a society and their impacts on mental health, finding a robust theory to help explain these changes is difficult. Nonetheless, it is apparent, both from the findings of this study as well as previous research that economic and political changes (which are invariable in today‘s world) can cause shifts in people‘s value systems. In Kuwait, it appears that value systems are

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currently shifting from conservative to liberal, one generation at a time, causing generations with opposing values to be in conflict with one another. This pattern has been found in Europe and

North America, and occurs even while controlling for individuals‘ tendency to become relatively more ‗materialistic‘ or ‗conservative‘ as they age (Inglehart, 1997; 2008; Palmer, 2014).

Therefore, based on the results of this study, it appears that Kuwait may be experiencing what

Inglehart (1997; 2000; 2008) described as a shift from materialism to postmaterialism (see

Chapter VI, Metatheme 3). This falls in line with what Karl Marx – who initially propounded modernization theory – predicted with his thesis: that democratic values are more likely to ensue after an economic upsurge (in Welzel & Inglehart, 2005).

On the other hand, periods of economic decline tend to have the opposite effect, whereby individuals become more ‗conservative‘ and authoritarian, and value tradition and economic security over individualism and autonomy. Therefore, Inglehart‘s (1997; 2000; 2008) theory illuminates two important findings of this study. First, it explains why virtually every participant who discussed the effects of the 1990 Iraq invasion – after which Kuwait‘s economy took a serious hit – felt that Kuwait became more conservative (i.e., resembling the conservatism during

America‘s ‗Great Depression‘). Second, it sheds light on why, after again gaining considerable oil wealth, younger generations began adopting more liberal values, resulting in major intergenerational conflicts in Kuwait (i.e., resembling the baby-boom culture in America).

However, unlike America in the post-World War II period, people do not have full freedom of expression in Kuwait, and therefore have relatively less academic and civil momentum than the baby-boomers of America. Consequently, the progression of social movements in Kuwait is relatively slow, if not stagnant – or, what Inglehart (1971) would argue, silent.

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This lack of ‗freedom‘ can explain why people keep their ‗liberal‘ attitudes and lifestyles

(e.g., having premarital relationships, abandoning religious values, or being homosexual) hidden from the rest of society to avoid being scrutinized and punished. A good (albeit extreme) example is the ‗sodomy‘ discussed earlier; this way, a woman can engage in ‗free love‘ without having to get her hymen restored and still claim to be a virgin to uphold her value as a ‗moral woman‘. This rise of an ‗assertive‘ counter-culture in Kuwait was discussed by many participants. Therapists generally felt that having to live a double life, along with experiencing multiple forms of abuse, are at the heart of the depression, anxiety, self-destructive behaviour and overall internal conflict and turmoil – or what one therapist called ‗cognitive dissonance‘ – that lands adolescents and young adults in therapy. Finally, living a double life and/or engaging in self-destructive behaviour also explains why personality disorders – particularly borderline personality disorder, characterized by self-destructive tendencies, extreme and conflicting perceptions (i.e., ‗splitting‘), emotions, and problematic attachment styles and behavious (APA,

2013) – are so frequently diagnosed in Kuwait by many mental health professionals, as seen in the previous chapter.

Given the overlap between Western values (or what are marketed as such) and postmaterialistic values, the line between postmaterialism and Westernization is blurred. Some research suggests that what Inglehart (1997; 2000) described as a postmaterialistic shift is merely a cultural adoption of Western values (e.g., Watenpaugh, 2014). Other scholars feel that modernity and Westernization are highly disparate but overlapping phenomena (e.g.,

Shirokanova, 2012). The interviews here suggest that what younger adults are experiencing is not necessarily ‗Westernization‘ because this transition from conservative to liberal is very likely to ensue in any developing society (Inglehart, 1997; 2000; Welzel & Inglehart, 2005). Just like

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Europe and Japan were used as benchmarks for technological innovation in the late 1880s and

1990s, respectively (Inglehart, 1997), the Western world, particularly North America, is now used as a benchmark for progressiveness among relatively less ‗modernized‘ countries such as

Kuwait. Therefore it is expected that individuals in any developing country will compare their budding progressive ideologies with those of the Western world, and that Western values will, in turn, influence them. It is common knowledge in the academic world that America has become a symbol for freedom, democracy and equality – not just in America, but also worldwide – despite how misguided that belief is (Klein, 2007; Lakoff, 2006; Wilkinson, 2011). This is also true in

Kuwait, where individuals will often feel that ‗everything is better in America‘ (P-9: 546-572; P-

13: 282-289).

The effects of dialectical change on mental health in Kuwait. On a more philosophical level, and as seen in Chapter V, this shift from materialism to postmaterialism can also be explained by Marx‘s version of the dialectical model (first discussed in a more naïve form by

Heraclitus and then Hegel), which proposes that all existing systems, large or small, experience adversity and follow a very predictable pattern of changes as conflicts and paradoxes accumulate over the course of time (Sherman, 1976; R. Coughlan, personal communication, March, 2014).

One way to understand the postmaterialistic shift in Kuwait is by bridging the gap between Marx and Inglehart by contextualizing postmaterialism within the broader parameters of the dialectical model (see Figure 2). In other words, we can view materialism and the traditional ideologies that come with it as a stable system (thesis) that is in the process of breaking down owing to the glitches, criticisms and inequalities associated with that system (entropy). These counterarguments and counter-ideologies (or the error of the system), which are now more progressive – or postmaterialistic – are beginning to enter public discourse and challenge the

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original system (antithesis). Therefore, the dialectical model predicts that there will be a high degree of tension between materialistic and postmaterialistic views before they get resolved and become a new, stable system, which will also experience the same predictable trajectory

(synthesis) that will then become the ―thesis‖ in the next phase of continuing development.

This conflict is seen within Kuwait‘s parliament itself. For example, we saw in Chapter

IV that the number of ‗liberal‘ MPs has been increasing in Kuwait, despite facing resistance from conservative parties (Moftah, 2015). The clash of ideologies at the political level is to be expected in Kuwait, as is the mental chaos that all this conflict at every possible systemic level ensues. Therefore, the perception that Kuwait is experiencing a ‗mental illness epidemic‘ brought on by a ‗tribal‘ culture, dysfunctional family dynamics, or biological or genetic factors (like many mental health advocates in Kuwait believe) is misguided, because all of these factors fail to consider the impact of political and economic changes on Kuwaiti culture – which is also in flux.

The argument here is that Kuwait is merely experiencing inevitable changes and the ―symptoms‖ of many mental disorders are reflective of these systemic conflicts. Many care providers and advocates, however, think these symptoms are caused by internal struggles or internal variables, however, it appears that these symptoms are more reflective of a modern social anomie in which individuals can deviate from the prescribed social norm and therefore have limited sources of support and structure that fit with their more modern worldviews. These ‗abnormal behaviours‘ should be viewed in light of these broader changes instead of being diagnosed – or worse, making attempts to suppress them by promoting inappropriate psychological testing and psychoactive drug use. This is especially true with regards to issues related to depression, anxiety, psychosis, and others, among migrant workers, women, children, and other people who are marginalized and abused in Kuwait. Contextualizing these issues in this way supports a more

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critical psychological view that places the onus of change onto political and governmental organizations who will otherwise be acquitted of any responsibility of reinforcing the oppression of vulnerable groups (Day et al., 2014; Fox et al., 2009; Teo, 2009). It also serves to remove blame from ‗culture‘ – both Kuwaiti and Western – and instead focus on increasing public awareness about the impact of economic and political practices on health, illness and overall wellbeing. This begins with an understanding of what drives systemic change, as we will see below.

The drivers of change, according to Marx, are the actual material practices that afford our survival in certain historical and cultural times, as we saw in Chapter V (R. Coughlan, personal communication, March, 2014; Foley, 1986; Marx, 1906; Sherman, 1976). In Kuwait, it is no longer necessary to live within the confines of gender norms, to allow your life to revolve completely around your work (if you‘re a man) and your family (if you‘re a woman), or to focus primarily on raising children to be engineers, doctors, or businessmen. Given that younger generations in Kuwait grew up in households that had more disposable income than their parents‘ or grandparents‘ generations did (Euromonitor International, 2014; Timetric, 2015), there is less incentive to dedicate their entire time to accumulating wealth and promoting their family‘s status. This economic shift has opened the opportunity to question existing worldviews, a striving for self-expression and fulfillment, and to pursue personal relationships and political philosophies that de-emphasize power hierarchies (Welzel & Inglehart, 2005). This was evident in the interviews, as well as Kuwait‘s rather active political climate in the past decade. For instance, as we saw in Chapter IV, it wasn‘t until 2005 that women were granted the right to vote after Islamic women activists began campaigning for political rights, and Kuwaiti women – particularly those who survived the Iraq invasion – dedicated their lives to political participation

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(Al-Mughni, 2010; The CIA World Factbook, 2016; Wills, 2013). Additionally, the interviews shed light on the fact that individuals who are oppressed, and those who work with, and for, these individuals, are becoming more conscious of the ways in which they and others are exploited as their narratives slowly penetrate public discourse.

Negotiating agency in the wake of modernization. In the previous chapter we saw that younger generations in Kuwait tended to be more likely to feel a greater need for ‗freedom‘,

‗self-expression‘ and having the desire to ‗choose‘ their own paths. This need for autonomy was largely associated with being ‗Western‘ or easily susceptible to Western media influences (see

Chapter VI: Metatheme 3). However, Inglehart (1997; 2000) would argue that these are merely postmaterialistic worldviews that younger generations adopt to develop more autonomy. Neo-

Freudian Erik Erikson (1968) would argue that these needs reflect the quintessential ‗identity crisis‘ – i.e., the psychosocial transition into adulthood when individuals chose roles (identities) that help them fit into society. Russon (2003) would argue that it reflects the natural desire for individuals to develop ‗habits‘ that support their roles as choosers; that reinforce the feeling that they ‗matter‘ to other people while at the same time feeling a sense of control in their lives.

Similarly, Gallagher (2012) would argue that this is merely a reflection of individuals attempting to reinforce their sense of personal agency by exercising conscious control over their personal circumstances and experiences. Although personal agency has not been studied in Kuwait and its literature is relatively scant in the Middle East at large, it appears to be an inevitable component of identity development, autonomy and feelings of empowerment across various other racial groups and ethnicities (e.g., Dwairy & Achoui, 2006; Schwartz, Côté, & Arnett, 2005). In terms of the phenomenological experience of the need for autonomy, the interviews somewhat echoed

Freud‘s (1920/1950) theory that individuals will inevitably feel anger and frustration, turned

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inward, or outward, whenever they are faced with a block to their innate desire for self- fulfillment – which he conceptualised as pleasure-seeking or pain-avoiding behaviour.

In light of these arguments, the constant vacillating between emotional inhibition/withdrawal and ‗over-expressiveness‘ that is often associated with borderline personality disorder (Salsman & Linehan, 2012) as well as living ‗double lives‘(i.e., ―splitting‖)

– where one life is inhibited, structured, and falls within the norms of what is expected by

Kuwaiti society, while the other one is more self-fulfilling, self-expressive, pleasure-seeking and liberating – may be reflective of the constant battle between Kuwait‘s tendency to inhibit

‗deviant‘ behaviour, and the individual‘s need for autonomy. A classic Freudian would believe that their desire for pleasure-seeking or pain-avoiding behaviour is being blocked, or that the typical ego in the young adult clinical population of Kuwait is conflicted (i.e, the id and superego are at it again), resulting in neurosis (Freud, 1923/1962; 1930/2005). On the other hand, Wade

(1997), whose theories are slightly different, yet overlapping with Inglehart‘s (1997; 2000),

Russon‘s (2003), and Gallagher‘s (2015), would say this person is ‗resisting‘ forces that are inhibiting their autonomy (which is far more empowering and conducive to the development of personal agency). Likewise, Marx would argue that this is a reflection of people‘s inevitable growing awareness that they are being oppressed and finding ways of promoting social change

(Sloan, 2009).

We also saw in the previous chapter that many individuals – particularly women – consciously found ways to feel more agentic by being more socially active, which involved accepting and adapting to some of the cultural norms in Kuwait. This involved choosing to adopt some religious beliefs, but not others, and appreciating certain norms and customs (such as dressing relatively conservatively and celebrating religious holidays), while abandoning others

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(e.g., refusing to wear the hijab, and seeking premarital romantic relationships). This also involved finding a balance between liberal (‗Western‘) and conservative (‗Kuwaiti‘) views, and adopting value systems that are conducive to their feelings of cultural integration and psychosocial wellbeing, while simultaneously rejecting those that are not. This conscious evaluation and adoption of both sets of value systems supports the finding that individuals who are more culturally ‗integrated‘ are more socially and culturally adapted, and experience greater subjective wellbeing (Sam & Berry, 2010).

Participant 2, for instance, intentionally chose what aspects of her mental health to discuss openly and what to keep private in a way that she could push some cultural boundaries

(e.g., by initiating public discourse on eating disorders and women‘s bodies), while also preserving her family‘s reputation by not discussing her personal struggles with matters that are considered more ‗taboo‘ in Kuwait. This was an act of personal agency because she was able to push certain social boundaries that would empower her and other young men and women who had similar personal struggles, while remaining cognizant of publicly discussing topics that would potentially damage her and her family‘s reputation. On the other hand, Participant 26 chose to take part in human rights advocacy groups to advocate for a community that experiences physical and sexual violence, even though it posed some risks to his own safety as a

South Asian, non-Arab and non-Muslim man. This was only possible through an act of what

Bandura (2002) described as ‗collective agency‘ since he intentionally cultivated relationships with powerful Kuwaiti-Muslims to promote the welfare of a vulnerable group. Similarly, a

Kuwaiti physician discussed how her and several other female physicians stood against hospital administrators who are currently attempting to segregate hospitals based on nationality; this was also an act of collective agency. In other words, the individuals who appeared more ‗agentic‘

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were those who demonstrated social problem solving skills as they clearly evaluated different perspectives, chose what values to adopt, and intentionally exhibited behaviours that allowed them to feel socially connected in Kuwait or participated in a collective effort to resist social injustice. The following section looks specifically at oppression, injustice, human rights violations and social exclusion among low-income and other socially fragmented populations in

Kuwait.

Neoliberalism, Inequality and Human Rights Violations in Kuwait: Mental Illness or Social

Defeat?

The notion that poverty is ―divisive and socially corrosive‖ was around before the industrial revolution (Wilkinson, 2011), and has become an axiom in modern global mental health research and action plans (e.g., WHO, 2013a). However, research from the past several decades has clearly and consistently demonstrated that it may not be low income per se, but relative low income within a nation, social fragmentation and subsequent feelings of social defeat – all of which are driven and exacerbated by neoliberal ideologies, race, class, and gender disparities that are driven by dominance hierarchies and are at the core of psychological distress (e.g., Fox,

Goldblatt & Jones, 1985; Gold & Gold, 2014; Kennedy, Kawachi, & Prothrow-Stith, 1996;

Prilliltensky & Nelson, 2009; Singer & Baer, 2012; Wilkinson, 1997; 1992; Wilkinson &

Pickett, 2009; 2010).

Relative inequality is a measure of wealth disparity between the wealthiest (e.g., the top

20%) and the poorest (e.g., the bottom 20%) of groups in a given country, while controlling for their GNP and GDP (Pickett & Wilkinson, 2015; Wilkinson, 2011; Wilkinson & Pickett, 2009;

2010). Countries such as Singapore, USA, Portugal, and the UK are considered to have high relative inequality because their income gap is extremely wide. On the other hand, Japan,

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Norway, Sweden, Finland, and Denmark have low relative inequality because their income gap is small – i.e., everyone has relatively equal access to resources compared to other countries.

Canada, France, Germany, and Switzerland fall somewhere in the middle of these two extremes

(see Pickett & Wilkinson, 2015). Countries with high relative inequality and unequal access to resources (e.g., healthcare and social support) have significantly higher rates of mortality, violence, anxiety, depression, addiction, and overall mental illness as well as lower levels of literacy, trust, life expectancy, and social support than those whose income gap is lower (Pickett

& Wilkinson, 2015; Wilkinson, 2011). Although there is no data that provides the relative inequality index of Kuwait, it is regarded as one of the richest countries in the world even though close to 45% of foreign workers (i.e., approximately 30% of Kuwait‘s population) are living in poverty relative to the rest of the population (extrapolated from Tamimi, 2013). Additionally, some sources suggest that low-income foreign workers outnumber local Kuwaitis (see

McKenzie, Theoharides, & Yang, 2014; Richards & Waterbury, 1998), therefore there is reason to believe that Kuwait has a high relative inequality index.

Social fragmentation. Social fragmentation is closely associated with relative inequality and is marked by the geographic and/or social exclusion of groups of people based on their race, social class, occupation, nationality or other common demographic factors that set them apart from the general population (Allardyce et al., 2005; Gold & Gold, 2014; Singer & Baer, 2012).

This often leads to unequal access to resources and therefore health disparities in the overall population (Gold & Gold, 2014; Singer & Baer, 2012). Based on the narratives in this study and some population health data, Kuwait is highly socially fragmented. Several participants, for instance, mentioned the district of ‗Jahra‘ when discussing the Bidoon (stateless immigrants) and

Bedouin (nomadic tribe) populations of Kuwait. Jahra is the agricultural centre of Kuwait and

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the largest of six districts since it occupies just over 70% of Kuwait‘s landmass (including rural uninhabited desert), according to recent census (Brinkhoff, 2015). It houses approximately 12% of Kuwait‘s population, while two other districts, Farwaniya and Ahmadi, occupy approximately

27% of Kuwait‘s landmass and house approximately 50% of Kuwait‘s population. Together, these three districts (which make up over 60% of Kuwait‘s population) are known to be highly segregated and populated primarily by Bidoons and Bedouins, but also low-income foreign workers. They are considered to be impoverished relative to the remaining three districts which make up only 3% of the landmass (including Kuwait city, the country‘s financial hub and main government and administrative offices) and 40% of the population. Low-income foreign workers are largely spread across 4 out of 6 of the main districts in Kuwait, and primarily live in overly crowded ‗labour camps‘ (shared spaces with other labourers) or in servant quarters with their sponsors (Bajracharya & Sijapati, 2012). The relatively middle and high-income Kuwaitis and foreigners primarily live in upper class neighbourhoods within the smaller districts in Kuwait – or in the case of some of the Royal family, in segregated high-security palaces. These districts are far more ‗modernized‘ – i.e., beaming with private luxurious hospitals and clinics as well as newly-built shopping malls flooded with Euro-American shops and restaurants. In short, Kuwait is a fusion of the Saharan desert, the slums of Mumbai, the San Francisco Bay Area with the occasional splash of Parisian and Islamic décor. As a Kuwaiti physician noted, ―it is a third world country, but with money‖ (P-11: 194).

Social fragmentation has shown to be a significant predictor of mental illness (Gold &

Gold, 2014). Psychosis, for example, is more common among individuals who cycle in and out of neighbourhoods and therefore have a lower sense of permanence, predictability, and control of their environments. This ‗transience‘ can lead to chronic anxiety in social organizations (e.g.,

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Sapolsky, 2005) as well as a 13-fold increase in psychosis relative to areas that are least fragmented (Allardyce et al., 2005). Social fragmentation is a predictor of psychosis and other

―mental illnesses‖ (e.g., depression and anxiety) across neighbourhoods within countries (e.g.,

Kirkbride et al., 2014) as well as across countries with varying levels of income inequality (e.g.,

Burns, Tomita & Kapadia, 2013; Wilkinson & Pickett, 2010).

Given that individuals, such as clinicians, who generally move in the more bourgeois circles of Kuwaiti society are less likely to experience hostility (e.g., P-3: 97-98; P-7: 222-228;

P-26: 85-88), it was not very surprising to hear how little emphasis was placed on Kuwait‘s dominance hierarchy in contributing to mental illness and illness disparities in Kuwait – particularly among those who operated within a biological or cognitive-behavioural model. For instance, the Bedouin and Bidoon tribes of Kuwait, who are relatively less wealthy, more agriculturally based and largely socially fragmented, are, by some, considered to be lacking in

―high education levels‖ (P-11: 135-143; P-14: 552-553). Therefore, they can be criticized, including by physicians, for having less mainstream (i.e., external) explanatory models for suffering – or what medical anthropologists would refer to as ―culturally constituted idioms of distress‖ (Singer & Baer, 2012, p. 23). Idioms of distress describe the source of one‘s painful lived experiences with an illness and the difficulty to manage it; examples include having a

―monster‖ living inside them (e.g., P-14: 556). Other idioms such as ‗demon‘, or ‗jinn‘ inhabiting a person‘s mind and body can underlie the pervasive feeling of helplessness, inexplicable fatigue and general emotional, physical, and mental defeat (i.e., ‗depression‘) among those living in the more rural areas of Kuwait. These individuals are also perceived to be more likely to present psychosomatic symptoms of emotional distress. Unfortunately, those who use very culturally nuanced idioms of distress were considered to be more primitive, more likely

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to practice tribal and ethnic endogamy (i.e., marrying within the same class/tribe) and culturally enforce consanguineous marriages (i.e., marrying within the bloodline). This phenomenon is considered to be common among more nomadic populations who aim to preserve the ―purity of lineage‖ and perhaps also ―to enlarge the tribe for socio-political gain‖ (Shah, 2004, p. 166).

However, one psychiatrist was very quick to compare more rural populations in Kuwait to ―the natives and aboriginals in Canada‖ (who are also stigmatized) and point his finger directly at consanguineous marriages in ―spreading the course‖ of ―diseases‖ such as substance abuse and psychosis (P-10: 238-247). He did this without acknowledging any of the social and political factors that can trigger (or at the very least, maintain) psychological distress such as a family‘s heightened emotional reactivity towards the sufferer (see Chapter II), racism, gender inequality, and other forms of oppression and marginalization.

In other words, some mental health professionals and physicians (as we also saw in the previous chapter) recast individuals who use cultural idioms of distress as ‗uneducated‘, thereby inadvertently supporting Jorm‘s (2012) goal to increase ‗mental health literacy‘ in Kuwait. The goal to ultimately create an ―enlightened [Westernized] healthcare policy‖ may be governed by the backdrop of neoliberal ideologies of Western pharmaceutical companies (Applbaum, 2006, p.

85), however we can see here that some mental health professionals – regardless of whether they are Kuwaiti or non-Kuwaiti – are too easily influenced by these ideologies and may even reinforce them. In other words, rather than dedicating valuable time and resources towards challenging some of the systemic socio-economic issues (i.e., relative inequality, social fragmentation and unequal access to resources) that may very well account for much of the

‗burden‘ of patients in their hospitals and clinics, many are instead striving to become so-called

―captains of industry‖ by practicing the art of disease mongering. This is currently widening the

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Kuwaiti market for pharmaceutical sales, and many clinicians do not even realize that they may be promoting more harm than good to their community – a global bioethical warning (e.g.,

Applbaum, 2006; Frances, 2013; Watters, 2010) that is largely ignored in Kuwait. This point is revisited later in this chapter.

The Kafala system. Low-income foreign workers, who are often exposed to more harmful medications (as we will see in the subsequent sections), appear to have an added disadvantage in Kuwait which was reflected in the several accounts of forced labour and human rights violations that they endure. This requires a discussion of Kuwait‘s Kafala system

(Bajracharya & Sijapati, 2012; Gardner, 2010) and its possible effects on ‗mental illness‘ in light of the ‗immigration effect‘ discussed by medical anthropologists and transnational and social psychiatrists (Bourque, van der Ven, & Malla, 2011; Bourque, van der Ven, Fusar-Poli, & Malla,

2012). The Kafala system was an offshoot of the rapid industrialization and economic development in Kuwait and several other Middle Eastern countries such as the UAE, Bahrain,

Oman, Lebanon and Saudi Arabia. It is also reflective of Kuwait‘s two-tiered labour market through which Kuwaitis receive a higher pay grade as well as more health and social benefits than expatriates on work permits (Fasano & Iqbal, 2003). This separates ‗Kuwaitis‘ from ‗non-

Kuwaitis‘. The Kafala system – although applicable to all non-Kuwaitis – is primarily targeted towards migrant workers from third-world countries who work specifically in construction, sanitation, and domestic labour positions (e.g., nannies, housemaids, and drivers). It is a neoliberal monitoring system whereby their ‗sponsors‘ are either Kuwaiti nationals, wealthy expatriates, or private organizations who can recruit laborers to work in Kuwait (Khan &

Harroff-Tavel, 2011). It also grants sponsors full legal right to control migrant workers‘ mobility and visa status, and also governs them by a different law than the labour law that governs

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Kuwaitis and other expatriates (Bajracharya & Sijapati, 2012). Essentially, the Kafala system rationalizes and enforces forced labour (i.e., slavery) and other human rights violations. The argument here is that they can also trigger and/or maintain psychological distress – the most severe being psychosis.

According to Marx (1906), rapid economic development propels proletarianization (i.e., the creation of a working class and slave labour), social class exploitation, and eventually rebellion as marginalized groups and their advocates become more frustrated and conscious of the ways in which they are exploited. Boswell and Dixon (1993), who expanded on Marx‘s theories, argued that income inequality, oppression, exploitation and revolt increase in countries that experience rapid economic development, depend on low-income foreign workers, and subsequently undergo a widening of the income gap. This theory has been supported by research in multiple countries (Beer & Boswell, 2001; Boswell & Dixon, 1993; Pickett & Wilkinson,

2015; Wilkinson, 2011) – including in the United Arab Emirates (see Buckley, 2013).

The pursuit of democracy in Kuwait appears to deviate slightly from Marx‘s prediction, but supports it nonetheless. Although I did not interview any low-income foreign workers, the previous section shed light on the fact that they are commonly forced to surrender their passports

(which is against Kuwait‘s labour law), experience forced labour, are beaten, raped, killed, tortured, imprisoned, institutionalized in a psychiatric facility, and/or left for dead in the desert.

Global human rights reports classify Kuwait as Tier 3 in human trafficking – i.e., the most problematic world-wide, since labourers are penalized for running away from abusive sponsors and labour agents and the Kuwait government has repeatedly failed to enforce global standards for reducing human trafficking (Gallagher, 2011). However, with the exception of running away or becoming violent with their sponsors, low-income foreign workers have very few avenues to

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resist maltreatment because their words carry no weight in court, and they fear being punished and deported back to their own countries – echoing a recent report on the experiences of Nepali domestic workers in Kuwait (Bajracharya & Sijapati, 2012). Some fear going back home because their small incomes in Kuwait (which can be as low as 200 Canadian dollars per month) are large enough to support their families in their home countries. Therefore, Kuwait is beginning to witness a gradual resistance – or revolt – by proxy. In other words, some powerful

Kuwaitis, foreigners who have personally experienced racial discrimination or violence, along with healthcare professionals who witness the physical and psychological impacts of abuse in their patients are beginning to advocate for human rights towards low-income foreign workers.

Revolt by proxy is necessary in Kuwait since foreign workers who attempt to advocate for themselves make little to no progress. For instance, single Indian women (who make up a large majority of domestic workers) were temporarily banned from coming to Kuwait from

1999-2001 by the Embassy of India after a large group of Indian domestic workers complained about their abusive sponsors (Oishi, 2005). The senior director of the government of India said,

―the best way to protect Indian women from abuse is not to let them go in the first place‖ (in

Oishi, 2005, p. 80). The ban was lifted after the Indian embassy was permitted to inspect work contracts, verify the employer‘s credentials, and the woman‘s parents were required to sign a ―no objection clearance‖ if she was unmarried (Oishi, 2005). However, this did very little to prevent abuse. After recurring complaints over the next decade, the Indian embassy again put a ban to

Indian domestic workers entering Kuwait in 2015, and the ban has recently been lifted after the

Kuwait government agreed to a ―mandatory submission of bank guarantee of US$ 2,500‖ for each ―Indian woman domestic servant‖ for the ―repatriation of the housemaid and other unpaid expenses‖ (Embassy of India, Kuwait, n.d. para. 1). Therefore, rather than addressing the actual

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issue at hand, it appears that the Indian embassy was more concerned with the responsibility of repatriation expenses rather than the actual welfare of their citizens. Effectively, Kuwaitis are able to (literally) buy, and according to Bajracharya and Sijapati (2012, p. 5), ―loan‖ workers and get away with mistreating them as long as they can cough up mere US$ 2,500 – thereby silencing any resistance by foreign workers by paying off the embassy or the sponsors who ―own‖ them.

Therefore, resistance or revolt by proxy appears to be the only avenue by which foreign workers can have their human rights met in Kuwait.

Immigration, racism, and social defeat. Although immigration to Kuwait – i.e., becoming a Kuwaiti citizen – is difficult (unless a foreign woman marries a Kuwaiti man), the vast majority of the population is made up of foreign workers and their families who settle and work (or study) in Kuwait on a long-term, but temporary basis. This is also true with other Gulf

Cooperation Council (GCC) countries such as Saudi Arabia, Bahrain, Oman, Qatar and the UAE.

Therefore, the immigration effect (Gold & Gold, 2014) is arguably applicable to temporary, but long-term foreign residents of Kuwait. The immigration effect in Kuwait denotes the many psychosocial nuances in GCC countries that may not be as visible in some Western countries

(e.g., Canada and the United States), where foreigners can often apply for citizenship rights after obtaining work-permits and contributing to the workforce (an exception is foreign farmworkers from Mexico and the Caribbean in Canada, who often undergo numerous human rights violations

[MacDonald, 2016]). Therefore, it is not so much the experience of being a non-Arab, but of being a non-Kuwaiti (or other non-GCC citizen) that can result in daily psychosocial hassles:

When you‘re non-Kuwaiti… you always feel like a stranger… you always think

that you‘re not home, there‘s always going to be something that grabs you

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down… [That] you‘re gonna fail one way or another… That one day, they‘re

going to send you back to your country (P-23, Lebanese service user: 196-201).

Being an immigrant has its own challenges in any country (Gold & Gold, 2014).

However, the narrative above highlights that feeling like an immigrant comes from chronic feelings of inferiority (or ‗failure‘) in the eyes of those who have the power to deport you, and demonstrates how power is used in Kuwait. This chronic feeling of subordination and pervasive fear of deportation consumes many foreigners (including foreign Arabs such as Egyptian, Iraqi and Lebanese men, women, and children) in Kuwait and other GCC countries. For instance,

Gardner‘s (2010, p. 198-199) ethnography of Indian low-income migrant workers in Kuwait‘s neighbouring country, Bahrain, demonstrates that the experience of ‗deportation‘ from a country feels less terrifying than ‗deportability‘ (i.e., feeling easily disposable based on your nationality).

Bajracharya and Sijapati (2012) also reported that deportability in Kuwait is one of the many fear tactics used to control a low-income migrant worker who can be punished on the grounds that he or she refuses to work overtime for no pay, declines performing sexual favours for a sponsor

(and in some cases, the sponsors friends and family), attempts to socialize with other domestic workers or, in the case of a woman, becomes pregnant with a Kuwaiti‘s baby. Deportation is probably the most merciful outcome for low income foreign workers in Kuwait since other alternatives include excessive overwork, no holidays, non-payment of salaries for months

(sometimes years), psychological, verbal, physical and sexual abuse, withholding of their passports as soon as they arrive Kuwait, and forced isolation, which includes forbidding workers to contact their families in their home countries or allowing them to leave the house that they are working in. Overtime pay is generally not granted to foreign workers if their host countries do not include overtime in their own labour laws (Bajracharya & Sijapati, 2012). In the event that a

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foreign worker responds by becoming violent, verbally abusive, attempting suicide or exhibiting any other ‗psychotic‘ behaviour, he or she is generally imprisoned or institutionalized, and therefore left at the mercy of local law enforcement or a psychiatric facility – both of whom are notorious for maltreating their foreign inmates and patients, respectively.

The perception that migrant or other marginalized groups are more likely to experience

(what may look like) psychosis, however, is not completely misguided. In 1932, Norwegian psychiatrist Ørnulv Ødegaard found that psychiatric disorders, particularly those related to psychosis, were significantly more prevalent among Norwegian immigrants in the United States than they were among Norwegian residents in Norway. This finding has been replicated in a variety of countries over the course of several decades, and there is no conclusive evidence to support Ødegaard‘s initial (and rather dubious) hypothesis that individuals with higher rates of psychosis are more likely to migrate to foreign countries (Gold & Gold, 2014). In their meta- analysis, Bourque et al (2011) compiled the data from similar studies conducted in the UK, the

Netherlands, Israel, Denmark, Australia and Canada that found that immigrants have, at the very least, a two-fold increase of presenting symptoms of psychosis than non-immigrant populations, which is about the same increased risk of experiencing psychosis after undergoing perinatal complications or persistently using psychoactive substances (Bourque et al., 2014; Gold & Gold,

2014). Some evidence to support the hypothesis that, in Gold and Gold‘s (2014) words, ―it is not the stress of immigrating but of being an immigrant‖, was found in children of immigrant parents

(i.e., second generation immigrants), who were born and raised in a foreign country, but still had the same increased risk of psychosis as their parents (Bourque et al., 2014; Gold & Gold, 2014).

Additionally, moving from rural to urban environments – though exacerbating the symptoms of

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psychosis – does not fully explain the psychological toxicity that can plague many foreigners

(Bourque et al., 2014; Gold & Gold, 2014; McKenzie, Fearon, & Hutchinson, 2008).

Social psychiatrists, epidemiologists and medical anthropologists have explored the psychological impact of being ―visibly foreign‖ (Gold & Gold, 2014, p. 128) – i.e., being

‗black‘, ‗brown‘, or ‗dark-skinned‘ (e.g., African, Arab, Bangladeshi, Caribbean, Pakistani,

Dutch Antillean, Latino, Moroccan, Surinamese, or Turkish populations) in stereotypically

‗white‘ countries such as the UK (e.g., Coid et al., 2008; Fearon et al., 2006), the Netherlands

(e.g., Veling et al., 2007), Sweden (e.g., Zolkowska, Cantor-Graae, & McNeil, 2001), Canada

(e.g., Seeman, 2011; van der Ven et al., 2012) and the US (e.g., Alegria et al., 2007; Budman,

Lipson, & Meleis, 1992). Overall, these studies demonstrate that darker skinned immigrants have an increased risk of psychosis as well as other (‗co-morbid‘) mental health issues such as depression, anxiety, and substance use in predominantly white countries. Additionally, Kirkbride et al (2008) found that Bangladeshi and Pakistani women in the UK had significantly higher rates of psychosis, regardless of their immigration and socioeconomic status. This finding suggests that it is not only being a minority, but also being a woman belonging to an ethnic minority group that can increase the risk of developing what appears to be a ‗mental‘ illness.

On the flip side, some studies have found that white immigrants have relatively lower risks of mental illness in predominantly white countries such as Australia (e.g., McGrath et al.,

2001) as well as predominantly non-white countries such as Israel (e.g., Corcoran et al., 2009).

In other words, it appears that racism (and possibly nationality-based discrimination) may be at the heart of much of the psychological torment that is inherent among immigrants. This is irrespective of the historical tendency of racially-biased clinicians to diagnosis ethnic minority groups (e.g., Africans) as having a mental disorder (Gold & Gold, 2014).

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The results of the current study provide qualitative support for this theory, where low- income foreign workers from third-world countries were described, by some, as experiencing more discrimination, humiliation, and human rights violations than those of Euro-American origin, or those who held had more prestige in Kuwait, regardless of race. For example, a prominent Sudanese psychiatrist in Kuwait, Dr. Mahmoud Suleiman, discussed in his autobiography the racism he experienced in his own country, while he felt very at home, and even blessed by the professional and academic opportunities that were granted to him in Kuwait

(Suleiman, 2010). On the other hand, the ―white‖ therapist who was moved to the front of the line at a local ministry, while the ―black‖ British man was asked to move to the back of a line at a mosque, was the classic example of blatant racism provided by two participants in this study

(see Chapter VI). Out of the twenty-six people interviewed, not a single participant made the specific connection between race, racism, and mental illness, with the exception of a human rights activist and former psychiatric patient who very early in his interview discussed, in-depth, how racism affected his mental health (P-26: 23-24; 89-90).

Critical psychologists such as Durrheim, Hook, and Riggs (2009) define race as ―a form of categorization that reflects particular power relations between groups rather than reflecting actual group attributes (physical or behavioural)‖; in other words, racism is the ―thinking and behaviour that seek to preserve race hierarchy‖ (p. 199). Therefore, unlike mainstream definitions of racism, critical psychologists aim to shift the focus away from beliefs and cognition and onto ―how individuals and groups are located in broader historical and social relations and how their identities emerge from these relations‖ (p. 199). In other words, it is not merely being visibly different, but also being situated along the lower social, political, and economic rungs of a dominance hierarchy on account of racial disrimination – and, in Kuwait‘s

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case, nationality-based discrimination – that widen (or at the very least, maintain) power differentials that are common in dominance hierarchies (Durrheim et al., 2009). The cumulative effects of these power differentials can be understood by examining the important, yet underinvestigated concept of social defeat (Gold & Gold, 2014; Selten & Cantor-Graae, 2005), which is examined next.

Social defeat is the forced display of submissive behaviour, which is often found in non- human mammals (e.g., rats), but has been used by anthropologists to understand human social interactions (Gold & Gold, 2014). Social defeat describes ―an actual social encounter in which one person physically or symbolically loses to another one‖, who ―demeans them, humiliates them, subordinates them‖ (Luhrmann, 2007, as cited in Gold & Gold, 2014, p. 136). In other words, those who consistently feel like second-class citizens owing to the ―chronic daily hassles‖ that they face based purely on their race, nationality, gender, and/or socioeconomic status are also more likely to feel chronically defeated (Selten & Cantor-Graae, 2005). Michael Marmot‘s famous Whitehall study provides a clear example of how low social status (including perceived status) can impact health to the extent that it can actually significantly decrease an individual‘s lifespan (Marmot, 2005; Marmot et al., 1991; Singh-Manoux, Adler, & Marmot, 2003). Echoing

Gold and Gold‘s (2014) argument regarding the social determinants of psychosis, it only seems reasonable that individuals may experience chronic feelings of social defeat or disempowerment to the extent that it increases their risk of developing serious mental health issues. In the next sections, I examine the public discourse on mental illness as applied to low-income foreign workers and argue that the liberal prescriptions of psychoactive drugs (particularly low-grade ones) and all the disease mongering that is now entering public lexicon may be silencing social reform in Kuwait.

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Drugs À La Carte: Silencing the Resistance of Oppressed Groups in Kuwait?

The mental health sector may be indirectly silencing the resistance of low-income foreign workers by claiming that they are mentally ill, need to be medicated, and should be screened for mental disorders prior to entering Kuwait owing to their violent behaviour (Kuwait times, 2014).

This is especially true for female domestic workers from Africa, whose violence can be pathologized as a mental disorder rather than acts of self defense, resistance or rebellion (e.g., P-

8: 1571-1599). To recount an extreme case from the Kuwait Times, one maid from Ethiopia

‗sacrificed‘ the daughter of her sponsor by slitting her throat, however it was difficult to determine her motive behind it. When asked about her motives, a local Kuwaiti psychiatrist who was interviewed about the case said,

Ethiopian housemaids suffer mental problems before coming to Kuwait [which]

soon escalate after a worker reaches the country, when they start feeling homesick

and lose interest in living in Kuwait… Mental problems are more common among

nationals of that country compared to other nationalities, which require immediate

action to stop their access into Kuwait (The Kuwait Times, 2014, para. 5).

When questioned about the social determinants of criminal behaviour, the psychiatrist said that ―social motives are limited in Kuwait‖ owing to the ―exceptional level of social security that citizens and expatriates enjoy‖. This is not an attempt to justify the perpetrator‘s criminal behaviour or claim that she was not mentally ill, but to highlight the fact that the psychiatrist turned a blind eye to the obvious socioeconomic inequalities that exist in Kuwait and solely blamed the individual for having ―mental problems‖ (The Kuwait Times, 2014, para. 4). This demand for psychological testing of labourers entering Kuwait echoes events in the US during the mass migration of immigrants in the early 20th century (see Chapter II). This was when the

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US Census Bureau required psychological reports on immigrants entering the US, and Kraepelin devised the notorious precursor to the DSM: The Statistical Manual for the Use of Institutions for the Insane (Greenberg, 2014). Some may argue that comparing modern psychological discourses in Kuwait to historical events in the western world is misguided or otherwise hypercritical, melodramatic, demonizing, or overly reactionary. However, Reicher (1996), who supports a more radicalized version of psychology, takes this comparison even further by reminding us of the events that took place when psychologists were asked to participate in the

Nazi movement. These psychologists not only provided the theoretical justification for eugenics

(by claiming that Jews are intellectually inferior), but not a single psychologist actively protested against extermination programs (Muller-Hill, 1988, as cited in Reicher, 1996). Given such

―wilful acquiescence‖ of psychologists towards one of the most horrendous acts of genocide in history (Reicher, 1996, p. 232), it would be irresponsible – and also unethical – to overlook some of these fallacies that left their mark on modern mental healthcare and underlie its principals and practices.

Psychological testing and disease mongering on a particular ethnic or racial demographic to appear ―socially relevant‖ (Reicher, 1996, p. 230) is just one of several avenues for mental health advocates to prove that their discipline is worthy of recognition and respect. As we saw in

Chapter II, this drive has consistently overridden the values of social justice and community empowerment to ease psychological suffering that modern mental healthcare is (supposedly) predicated on (WHO, 2013a). This can be further understood through the poignant writings of prominent British social psychologist Stephen Reicher (whose work informs some of the key ideas in the final section of this chapter):

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The ultimate irony is that we have bought our own autonomy as academics at the

cost of denying autonomy to those that we study. To risk a poetic allusion: we

have bought our own freedom at the cost of everyone else‘s soul – a truly

Faustian contract. Such limiting concepts of the discipline are not only

intellectually impoverishing, they also have direct political consequences… The

proliferation of psychologies which deny agency is part and parcel of constructing

both a passive subjectivity and pacifying social practices. In Foucauldian terms it

is a technique of governance. From a Marxist perspective it is important to add

that it is a governance in opposition to social change. (Reicher, 1996, p. 237).

The demand for psychological testing in Kuwait also closely resonates with a recurring pattern which first occurred in Europe and North America followed by the non-Western world as mental health advocates and professionals transformed their care practices during the last century

(see Chapter III). To turn mainstream North American psychology‘s four areas of functional expertise of surveillance, prediction, manipulation, and thus control and to use these as lenses in viewing the mental health discipline itself, we can predict that the outcomes of these discourses are going to work against social reform in Kuwait in the long run.

Currently, regardless of whether or not low-income foreign workers are tested for mental disorders, they generally walk away with a prescription from their primary care physicians or psychiatrists. For instance, Participant 14 said that many of the housemaids she sees suffer from severe depression: ―I am starting antidepressants for a lot of maids‖ because their sponsors ―are not giving them the rights to [freedom]‖ or ―the space to express their needs‖ (569-575). She also felt that she avoids explaining some of the negative side-effects of SSRIs to housemaids because they won‘t understand them:

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[It‘s] because of [their] low IQ, you know? …I cannot blame [them]. [They‘re]

not educated [and] will not understand anything… [So] it is easy for me to give

anti-depressants and explain depression and anxiety to a maid… It‘s very easy…

They accept it… A lot of Philipinos, Ethiopians, Indians, Sri Lankans… They

accept having anti-depressants, and they‘re very happy to take it. And they are

compliant… But with the Kuwaitis? Ooof [humorously] it‘s very difficult! (P-13:

605-613).

We can see here that Participant 14, a primary care physician, felt that low-income foreign workers are ―easy‖ and ―compliant‖ patients because they are ―not educated‖ and accept taking SSRIs, while Kuwaitis may be more hesitant. However, much of the depression among housemaids appears to stem from a lack of freedom, forced labour, and ―being away from their kids [and] loving people‖ (574) – i.e., social defeat – rather than a chemical imbalance. Again, this resonates with the events that took place in Japan after their market crash in the 1990s; as individuals suffered from depression owing to excessive overwork, their need for mental health services increased and physicians began to liberally prescribe SSRIs (Applbaum, 2006;

Kitanaka, 2006). This numbed workers‘ (very valid) negative emotional reactions to their oppressive work environments, and therefore acted as a barrier to protesting against their employers. Instead, as Kitanaka (2006) learned from her interviews with them, they began protesting against their own psyches, which had now become ―work hazards‖ without the emotional numbing effects of their medication. Similarly in Kuwait, low-income foreign workers are now asking for SSRIs because they supposedly help them ―work more‖ and ―earn more money‖ (P-14: 601). It is difficult to say whether this increased productivity is an actual effect of the medication or merely a placebo effect. However, the bottom line is that this, along with

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inpatient antipsychotic treatments which render patients emotionally ―numb‖ (e.g., P-8: 2254) are beginning to silence the impetus to actively resist inhumane working environments. Like

Participant 5 observed, ―instead of saying, ‗okay, what can we do to [help] this person?‘‖ physicians will generally ―give them pills‖ to ―keep them quiet and just shut them up‖ (382-394).

These practices bring to mind some of the contemporary theoretical concerns addressed by critical psychologists (e.g., Coates & Wade, 2007; Danziger, 1997; Teo, 2009; Wade, 1997): that rather than questioning how an individual or a group may be alienated, some professionals will generally assume that their individual cognitions and behaviours are not adaptive. This echoes the theoretical underpinnings of a functionalist or cognitive-behavioural psychology in which constructed concepts such as mental illness are assumed to be ―natural‖, biological or mental concepts owing to their empirical support (Danziger, 1997; Teo, 2009). However the premise or ontological status of a concept such as mental illness is seldom questioned (Teo,

2009). In the upcoming passages I address how economic and social fragmentation, which was discussed earlier, also results in healthcare (including mental healthcare) fragmentation in

Kuwait. This contributes to the overestimation of the role of individual differences on mental illness, and therefore parallels some of the problematic global mental health practices that rationalize the further subjugation of already oppressed groups. In effect, mental healthcare as a discipline and service aligns itself more with an oppressive government rather than with movements of resistance, social justice and human rights. This raises two critical questions: 1) how is public discourse about mental health and illness used to transform public consumer consciousness? And 2) what bioethical concerns does this raise in Kuwait?

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Socially Marketing Mental Illness in Kuwait

In Chapter III, I discussed a very poignant ethnographic commentary that medical anthropologist

Kalman Applbaum conducted at the World Psychiatric Association (WPA) in Yokohama, Japan

(see Applbaum, 2004). He described, satirically, how aspiring clinicians and other health professionals were greeted by well-dressed hosts, treated to gourmet meals and interacted with the representatives of GlaxoSmithKline. As a side note, GlaxoSmithKline, just a few years ago, paid US $3 billion for the off-label marketing of 10 medications (including antidepressants Paxil and Wellbutrin), making it the ―largest healthcare fraud settlement in US history‖ (BBC, 2 July

2012, para. 1). Apart from bribing doctors (i.e., offering kickbacks) with Hawaiian vacations, concert tickets, and hard cash to promote their medications globally (BBC, 2 July 2012),

GlaxoSmithKline also provided Japanese health professionals with the ―virtual reality simulators‖ (originally created by Janssen Pharmaceuticals – a subsidiary of Johnson and

Johnson) that allowed physicians to finally see what their schizophrenic patients were describing.

As we saw in Chapter III, this was one of the events leading up to bridging gaps between

American and Japanese healthcare and economic practices (e.g., ―The US-Japan Framework‖).

The reason this example is so critical to the analysis of mental health and illness discourse in Kuwait is that these events just recently took place in Kuwait as well when ―scholars from the US‖ visited the Kuwait Center for Mental Health for what appeared to be a mental health ―fieldtrip‖ for American University of Kuwait undergraduate students (AUK, 2015). One purpose of this trip was to demonstrate the use of the virtual reality simulator: a ―new technology‖ that ―enables individuals to experience delusions and hallucinations‖ like those of schizophrenic patients. Unfortunately, I was not in Kuwait to partake in the event, however based on the article, psychology undergraduate students were targeted for the purpose of

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marketing new technologies (and therefore the disease categories they help manage), and destigmatizing mental illness. Additionally, in 2014, there was a ―joint Arab-American commission‖ headed (i.e., funded) by the National Institutes of Health (NIH) in the United

States, selecting at least one local psychiatrist in Kuwait to present at the ―Arab-American

Frontiers of Science, Engineering and Medicine Congress‖; who was also selected as the

―Bipolar Scholar‖ in the Middle East by the International [American] Society for Bipolar

Disorders (Alsuwaidan, n.d.). Lawmakers have accused executives at the NIH of encouraging corruption: ―As the Pfizer-Neurontin documents reveal, pharmaceutical companies pay physician-scientists for their valuable service as product promoters – not for their scientific services‖ (Sharav, 2006). These events are almost an exact replica of the events that took place in

Japan, as anti-stigma campaigns became rampant and mental illness entered the public lexicon.

As a side-note, even bipolar disorder experienced the same ―false epidemic‖ as ADHD, autism, depression and anxiety disorders, for which millions of people received medication.

Social marketing experts such as G. D. Wiebe have known since the 1950s that if you want to sell an idea, market it the same way you would market a product: ―to bring about desired exchanges with target audiences‖ (Kotler & Zaltman, 1971, p. 4). In the first example above, the target audience was not only young, aspiring psychologists in Kuwait, but also the general public. The marketed product was not the virtual reality simulator, but the idea that mental health professionals as well as the manufacturers of modern technology (including modern medicine) are the sole experts at understanding mental health and illness (rather than the patients themselves), and are capable of passing down that expert knowledge to academics and the general public. The terms ―ethical‖ and ―non-invasive‖ treatment procedures attempt to humanize and rationalize clinical practices in Kuwait, despite the evidence (from this study, as

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well as a previous study) that service users often have very negative experiences with mental healthcare in Kuwait (e.g., Scull et al., 2014). The negative perceptions about mental health services, however, were effectively recast as ―stereotyped and prejudiced‖ by a local prominent psychologist who defended psychiatric practices in Kuwait and felt that meeting with psychiatric inpatients was a real ―eye-opener for the students‖ (AUK, 2015, para. 9).

Not only do these discourses sell the idea of mental health clinicians as being ‗experts‘

(placing them in a higher position of power and authority), it also markets the concept of an individualized version of mental illness. Interestingly, this resembles western colonial discourses: Coates and Wade (2007), for example, used a clever analogy to compare the misrepresentation of individuals diagnosed with mental disorders to the discursive practices used by European colonizers of aboriginal populations. These atrocities against aboriginals were justified on the grounds that they had ―presumed natural deficiencies‖ while Europeans possessed ―God given superiorities‖ (p. 512). The inhumane treatment of aboriginals was publicly concealed by discourses that ―valorized the pioneer-missionary‖ and failed to address the genocide and ethnocide that was used to disempower a particular group. These colonial discourses have directly influenced some mental health discursive practices which ―misrepresent

‗others‘ as deficient and therefore as in need of assistance from proficient authorities‖ (emphasis added, p. 512). Likewise, in Kuwait, some mental health professionals are beginning to misrepresent many mental health service users such as low-income foreign workers – particularly African women – as lacking in the psychological skills to help them ‗adapt‘ in

Kuwait. For instance, in the AUK (2015) article published online, the writer noted that the female in-patient ward of the Acute Unit at a local mental health facility primarily treated domestic workers who supposedly suffered from bipolar disorder, schizophrenia and adjustment

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disorder. These discursive strategies are, effectively, used to sell the idea that domestic workers from third world countries have natural individual deficiencies. The presence (and mention in the article) of ―visiting scholars from the US‖ acted to valorize and legitimize ―non-invasive and more commonly used treatment methods‖ (i.e., psychoactive drugs) for those suffering from mental illnesses, thereby leading to the ―universalization of categories of sickness‖ (Singer &

Baer, 2012, p. 163) to promote prescription psychoactive drug use rather than contributing knowledge about the endemic problems of social injustice in Kuwait. The next section examines the bioethical concerns surrounding the social marketing of modern mental healthcare in Kuwait, and emphasises the added role of unequal access to mental health facilities in Kuwait.

Bioethics in Kuwait

Countries that are highly economically and socially fragmented also happen to be the same countries whose healthcare systems are fragmented – i.e., not all individuals have equal access to quality healthcare and social support, further creating health (including mental health) disparities in a nation (Singer & Baer, 2012). There are multiple lines of evidence to suggest that this is true in Kuwait as well. For instance, we saw earlier that only the wealthy can gain full access to a range of professional clinical psychology, counselling/psychotherapy services. These services are found more in the private than public sector, are not subsidized by the Ministry of Health, and are very expensive – reaching upwards of 70 dinars (CAD $300) per session (outside of school and university settings). Those who cannot afford these services (i.e., the majority of the population) have no choice but to see physicians (psychiatrists and family doctors) in public healthcare settings, whose primary mode of treatment is medication. Additionally, there is no

‗first come first serve‘ policy in Kuwait‘s public health settings for walk-in patients, as Kuwaitis are typically given the first ‗time slots‘ to see a physician, even if non-Kuwaitis have been

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waiting longer. Finally, Kuwaitis and non-Kuwaitis can receive different quality medications for the same psychiatric diagnosis (P-8: 2147-2191). For instance, if a psychiatrist wants to curb psychotic symptoms in a Kuwaiti patient, the Ministry of Health subsidizes newer atypical antipsychotics (e.g., Risperdal, Zyprexa), which – despite having the relatively same level of

(non)efficacy as typical antipsychotics – have a ―much more favourable side-effect profile‖

(Frances, 2013, p. 89). On the other hand, non-Kuwaitis are forced to use high potency, typical antipsychotics (P-8: 2157-2158) that were manufactured in the 1950s (e.g., Haloperidol), and are much cheaper today (Frances, 2013, p. 89) – unless, of course, they pay for ‗high quality‘ ones out-of-pocket, which are often very expensive (e.g., a monthly supply of can reach upwards of

90 KD or CAD $350 – which is more than a month‘s salary for most domestic workers) (P-8:

2184-2185).

The use of older, typical antipsychotics are far more likely to result in the ―characteristic look‖ of a psychiatric inpatient: ―the fixed stare, rigid posture, tremors, abnormal movements, and drooling‖ (Frances, 2013, p. 89), or the ―tardive dyskinesia‖ (P-7: 449-450) and overall

―dullness‖ (P-8: 2248) that plagues many who are on typical antipsychotics. A Kuwaiti psychiatrist who routinely challenges the way psychiatry operates in Kuwait recounted, dejectedly, ―you feel very sorry for those high IQ, highly educated patients, [who] become numb.

They cannot think as clearly, they lose their creativity, [and] their emotional reactivity‖ (P-8:

2250-2255) – the very characteristics that make us human. She also noted that more recently manufactured (and therefore more expensive) serotonin norepinephrine reuptake inhibitor

(SNRIs) class of antidepressants are only subsidized for Kuwaitis, while non-Kuwaitis are prescribed older, ‗lower grade‘ antidepressants (i.e., SSRIs) such as Prozac, unless, again, they can afford and are willing to pay out-of-pocket for more ‗effective‘ ones (P-8: 2189-2191).

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The events in Kuwait are beginning to echo what Allen Frances, the head of the DSM-IV

Task Force, described in the US (Frances, 2013): that high income populations can afford the luxury of private psychotherapy and counselling, while low-income groups are left with governmentally subsidized psychiatric services (e.g., via Medicaid) which are limited to short patient visits, institutionalization, and psychopharmacotherapy – if not imprisonment. With the exception of providing the odd charity session to a low-income foreign worker, clinicians who are more socially-oriented and have experience in community development and empowerment, and working with migrant populations are, ironically, working in high-paying, private clinics that target upper-class Kuwaitis and foreigners (see Chapter VI, Section 3.4). According to Frances

(2013), those who really need proper mental healthcare and social services rarely receive them and are instead sent off with a prescription, while far too much attention is given to ―the normal worried well‖ in private practice (emphasis added, p. xv).

The previous section demonstrated how resistance among low-income foreign workers is silenced in Kuwait. First, foreign embassies are doing little to support their citizens in Kuwait, especially when they are paid off by the individuals or private corporations who hire them.

Second, some physicians are inhibiting the natural human tendency to resist harsh treatment by medicating and thereby numbing those who are exposed to them. In the following section, I propose some possible policy initiatives that will help propel social reform, and hopefully decrease the inappropriate and widespread use of psychiatric medication in Kuwait. Finally, I discuss how Kuwait‘s mental health system – which is currently following in the footsteps of

North America‘s – can take a few steps back and resurrect some ancient and holistic philosophies of healthcare, which, interestingly, originated in the Middle East.

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Chapter VIII. From Clinical to Critical Practice: Reconceptualising the Role of Mental

Healthcare to Promote Public Discourse on Health and Social Justice in Kuwait

Mental healthcare, as we know it today, has always attempted to take on the role of being

―socially relevant‖ (Reicher, 1996). From empowering those who have suffered an abusive environment to silencing the persecutory voices inside a patient‘s mind, mental healthcare has become an integral component of a caring society. However, intentionally or unintentionally, many organizations and community members that provide mental health and other support services maintain caregiving practices that are often unjust and inequitable (Evans & Loomis,

2009). What exacerbates this further is that mainstream (i.e., experimental and scientifically derived) psychological, psychiatric and medical training modules – unlike those of social work – are relatively less equipped to provide current and aspiring caregivers and community activists with the theoretical and practical tools necessary to challenge injustice, channel collective action, and propel transformative community and political change (Evans & Loomis, 2009;

Prilleltensky, Prilleltensky, & Voorhees, 2009; Steinitz & Mishler, 2009; Welzel & Inglehart,

2005). The purpose of this section is to help reconceptualise mental healthcare in Kuwait by demonstrating how political dynamics are intertwined with psychological wellbeing and what caregivers and academics can do to align themselves with existing, but silenced movements for political action and community care.

The previous sections identified several oppressed populations in Kuwait: all individuals

– particularly women and children – who have endured physical or sexual abuse, low-income foreign workers who experience numerous human rights violations, and the Bidoon and Bedouin tribes of Kuwait who are highly fragmented from the rest of Kuwaiti society. Substance users – both male and female – and LGB (lesbian, gay, bisexual) groups are also prone to humiliation

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and stigmatization in Kuwait. Finally, those who suffer from schizophrenia and other forms of psychosis (actual or misdiagnosed) often don‘t receive appropriate care and are subject to discrimination, marginalization, and sometimes ―bondage, isolation, or unwarranted institutionalization‖ (Kaladchibachi & Al-Dhafiri, 2016, p. 2). The two factors that contribute to this are public and internalized stigma and the overarching resistance towards mental health services, according to recent reports of unethical treatment, confidentiality breaches, and oppressive language employed by some caregivers (Almazeedi & Alsuwaidan, 2014;

Kaladchibachi & Al-Dhafiri, 2016, p. 2; Scull et al., 2004). In addition to supporting these findings, the current study also identified that some Kuwaitis feel offended when prematurely prescribed psychiatric medication, or when they or a family member is ―labeled‖ with a DSM or

ICD disease category that undermine existing cultural idioms of distress.

Owing to the depth, richness, and multitude of social and mental health issues discussed in Kuwait, I‘ve divided this final section into several sub-sections. First, I discuss the recommended therapeutic approaches for families experiencing ‗intergenerational conflict‘ – a phenomenon that is quite common in modern Arab-Muslim societies (e.g., Al-Krenawi &

Graham, 2000; Scull et al., 2014), as well as other societies that experienced a ―post-materialistic shift‖ in worldviews (Inglehart, 1971; Welzel & Inglehart, 2005). I then focus on larger, more problematic issues in Kuwait that form the main themes of this chapter: the lack of ethical service delivery, the push for anti-stigma campaigns (and how to mitigate diagnostic inflation), and the push for de-centralizing mental health services (which is a promising goal, however has some caveats that need to be addressed). This is then followed by a discussion on how the mental health sector in Kuwait can save itself from ridicule by giving voice to, and aligning with, movements of human rights and social justice in Kuwait.

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Is Mental Healthcare Equipped to Resolve “Intergenerational Conflict”?

And should we care? Many therapists‘ narratives resonated with the idea that the principals of care, such as helping their clients cultivate feelings of empowerment, are the same regardless of what country they are practicing in; it‘s putting these principals into practice that is quite different in Kuwait. They reported on the cultural and contextual factors that shape how mental health and social issues are presented in Kuwait and also provided some valuable insights on how caregiving practices need to be modified with many Kuwaiti clients. Many young men and women were described as feeling ―trapped‖ and ―restricted‖, which paralleled what many service users reported as well; that they are often ―torn‖ between choosing their own life trajectory and going against their family‘s wishes (e.g., in terms marriage, appearance, lifestyle, and/or educational/career paths). When pressured to uphold traditional family values, many individuals develop the tendency to ―live a double life‖, characterized by habitual lying and cultivating multiple lifestyles that are often at odds with each other, resulting in extreme identity crises (an extreme case is the young woman who wears a hijab by day, but then engages in heavy drug use and risky sexual behaviour by night). Rather than viewing these behaviours as a method of

‗resistance‘ to what is perceived, by many young adults, as conservative value systems, those who align with a more disease-centered view of mental illness may recast these behaviours as

‗borderline‘ (or ‗bipolar‘) and subject them to unnecessary psychological testing and psychotropics. The therapists who were not trained in medicine, however, generally felt that many DSM categories – albeit helpful for clinicians to share amongst themselves – are not particularly applicable in Kuwait. They also felt that many of their clients were on medications that they didn‘t need. They reasoned that most mental health issues stemmed from miscommunication and ideological conflicts between older and younger generations, rather than

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an actual mental disorder, neurochemical imbalance, or what some aspiring clinicians and mental health advocates would call ―real biological or behavioural illnesses‖ (e.g., AlHomaizi &

AlHomaizi, 2014).

Additionally, because relationships are more ―intensified‖ in Kuwait, helping service users develop a strong sense of identity and autonomy (i.e., helping them become ‗individuals‘) that conflicts too much with their family values may not be beneficial after all. In fact, one therapist felt that by grounding therapy in a ―North American‖ individualistic framework she was bringing many of her clients into direct and sometimes aggressive conflict with their families (P-7: 844-846). This supports Al-Qimlass‘ (2015) argument that Kuwait needs to be cautious of ‗Western‘ models that emphasize individualism. This is particularly true for female

Arab-Muslim clients who are generally not allowed to exit their family environment until they get married. Therefore, autonomy is not something that can be asserted in Kuwait, but must be negotiated within the family: ―you need to work with the family through the individual‖ (P-3:

359-360), and vice versa. This is further supported by the finding that those who found value in some of Kuwait‘s social norms were more culturally integrated and demonstrated a stronger sense of personal agency. Therefore, issues stemming from intergenerational conflict may require therapeutic approaches that take broader contexts in account such as multicultural counselling and therapy, social work, and family therapy that help clients evaluate their cultural identity, recognize their own resilience and help develop the discursive skills necessary to negotiate their autonomy within more ―conservative‖ or ―authoritarian‖ families and communities (Prilleltensky et al., 2009).

Although many therapists felt that it was important to remain flexible with their approach, they also felt that placing a heavier emphasis on more person-centered rather than

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problem-centered therapy was very psychologically rewarding for themselves and their clients.

They felt that building rapport, or ―connecting‖ with a client fosters a more trusting relationship, allows both therapist and client to acknowledge the client‘s resilience, and becomes a foundation for empowerment. Given that there is a relatively high emphasis placed on interpersonal relationships in Kuwait, interpersonal therapy that emphasizes ―genuine care and understanding‖ can go a long way in motivating clients in their own lives, and helping them see their own resilience in the face of social challenges (P-13: 480-491) – a resilience that is often undermined in more conservative family environments, or therapeutic relationships that focus on ―fixing‖ the individual. This was supported by interviews with service users: those who felt that their therapists tried to ―fix‖ them tended to drop out of therapy.

To answer the question, is mental healthcare equipped to resolve intergenerational conflict (and should we care)? The short answer is no (with the exception of serious cases where hard substance abuse, violence or more debilitating psychological issues are also present). This is owing to the sheer fact that the more socially-driven caregiving practices are, ironically, often privatized, expensive, and therefore inequitable. Additionally, the conflicts that arise are largely owing to the very normal socio-political shift towards post-materialism that happen in all industrialized societies (Inglehart, 1997; Welzel & Inglehart, 2005) - particularly among upper

SES families, giving rise to what many health professionals would call ―the worried well‖ (e.g.,

Frances, 2013, p. xv; Singer & Baer, 2012, p. 164). We could argue that those who are constantly worried aren‘t particularly well and could perhaps benefit from a little tête–à–tête with a qualified professional; however this doesn‘t change the fact that the vast majority of Kuwait‘s population is neglected.

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This begs the question, how can we make mental healthcare more equitable in Kuwait? The arguments that are beginning to arise in Kuwait are that mental healthcare needs to be: (1) guided by more ethical principles and practices; (2) de-stigmatized; and (3) de-centralized and community-based (Almazeedi & Alsuwaidan, 2014; Al-Qimlass, 2015; Kaladchibachi & Al-

Dhafiri, 2016; Scull et al., 2014). This was also the general consensus among participants interviewed in the current study.

Ethical Service Delivery

When asked how mental healthcare can be more ethical in Kuwait, participants felt that a governing ethical body that enforces confidentiality is the most important since that‘s one of the biggest barriers to people seeking care. This prompted some clinicians to establish the Middle

East Psychological Association (MEPA) in 2010 to unite mental health professionals in Kuwait and other Middle Eastern countries and inform ethical caregiving practices and codes of conduct that are largely based on the American Psychological Association (APA) and the Turkish

Psychological Association (MEPA, 2011). Recently, psychiatrists have formed the Kuwait

Psychiatric Association (KPA), however their goals – other than ―planning several educational and social events over the next two years‖ – are still unclear. As it stands right now, none of these associations have yet been recognized by a legislative body in Kuwait or the Middle East at large (Al-Qimlass, 2015; MEPA, 2011). Almazeedi & Alsuwaidan (2014) estimated that approximately 50% of family physicians, who diagnose and treat mental illnesses in Kuwait, are not board-certified; therefore, they felt that there is a dire need for more board-certified clinicians in Kuwait. Similarly, interviewed clinicians felt that most therapists (including psychiatrists, counsellors, social workers, and clinical psychologists) don‘t have the training and skills

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necessary to provide adequate mental healthcare: ―licensing exams would automatically eliminate 80% of clinicians practicing in Kuwait‖ (P-3: 583-584).

However, there is reason to believe that education is not necessarily a major predictor of service quality. For example, the perception that so called ―Western-trained, board-certified clinicians‖ are ―ethical‖ is being shattered – both in Kuwait, and globally, owing to some rather compelling evidence from the current study as well as previous studies (Applbaum, 2004;

Frances, 2013; Greenberg, 2013; Healy, 2006; Petryna, 2006; 2011; Watters, 2010). In Kuwait, some clinicians felt that they largely become acculturated into an environment in which there is no oversight of what should be considered ethical service delivery: ―mediocrity is corrosive and it becomes contagious… People begin to lose those standards‖ and ―conform to broader systemic problems‖ (P-3: 245-274). Such systemic problems include a potential ―kick-back system‖ which is illegal in most countries: ―I‘ve had clients and friends tell me that… If a psychologist refers to a particular psychiatrist, or vice-versa, then the referring clinical will get money for it‖ (P-3: 284-

286), however there is no way to verify this unless physicians self-report it. One board-certified physician I interviewed felt that she was more ethical in the West than in Kuwait because ethics are relatively more enforced in the West; that ―lying‖ and ―cheating‖ is normal and expected in

Kuwait. She admitted, ―my ethics are a little bit shady… It‘s normal to cheat!‖ (P-11: 64-68).

Similarly, a board-certified clinical psychologist (who was in fact highly ethical) said, ―we don‘t have to use any ethics if we don‘t want to; there are no rules!‖ (P-13: 802-803).

What makes matters regarding ethics more complicated in Kuwait is that some clinicians who adhere to a ―code of ethics‖ (e.g., ―first do no harm‖) can face some serious backlash from families. For instance, Participant 4 felt that it is easy for mental health professionals to get

―swept away‖ by playing the role of ―authority‖ because they‘re dealing with a population who

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expects and sometimes also accepts it (P-4: 2165-2187). She also noted that some families try to

―extract information‖ from their therapists (P-4: 1704-1706). If a therapist refuses to disclose any information about their client, some families can resort to ―trashing‖ them and accusing them of

―not caring‖ (P-4: 1709-1711): ―it‘s easy to get swept away in family dynamics‖ and clinicians

―need to be okay with pissing off a lot of people‖ (P-4:1715-1726). However this becomes more complicated for medical professionals, in particular. Two participants recounted the event of a psychiatrist getting ―beaten up‖ by the family of a young adult woman for allowing her to leave the psychiatric hospital since she wasn‘t a threat to herself or anybody else, and felt that she was in danger if she went back home (e.g., P-4: 2265-2274). There were also other accounts of psychiatrists getting bullied into making unwarranted diagnoses, providing medication, and writing unnecessary ―sick-leaves‖ for patients (―malingerers‖), who want a ―secondary gain‖ such as ―retirement‖, ―compensation‖, or ―disability pensions‖, or in less extreme cases, exemption from an exam (P-10: 54-57; P-14: 408-415): ―we have people coming in with machine guns, forcing doctors to prescribe benzodiazepines‖ even when a prescription is unwarranted (P-10: 47-48). With the exception of having your life threatened, none of these explanations justify breaching ethical codes of conduct, but they certainly provide compelling explanations for why and how ethical breaches can occur in Kuwait.

A critical and cultural take on ethics. Most participants discussed policies and practices that fall in line with existing Western definitions of ethics: primarily in terms of code of conduct

(e.g., being less ―authoritarian‖) and confidentiality. One therapist (Arab female), who identified as a feminist, also made the connection between language (i.e., how ethics is discussed) and mental health practice:

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Here‘s the overarching theme: whatever model that I came up with would give the

client a lot more power… It would be a lot less doctor-patient, and more

client/consumer-healthcare provider… You‘re here voluntarily, you‘re not here

because you need to be fixed… I would definitely let that type of language

permeate whatever the policy was. (P-4: 2577-2587)

Her narrative resonates very strongly with Teo‘s (2009) critical argument that if language assumes people ―act like machines‖, where the emphasis is on ―control‖ and ―adaptation‖ (i.e., getting ―fixed‖), then clinical practice will invariably resort to manipulating individuals, and controlling the population (pp. 47-48): ―[language that pathologizes] gets very dangerous because there are a lot of narcissistic, power-hungry people out there who like control‖ (662-

663). Conversely, if the language we use views people as ―meaning-making agents‖ within broader linguistic and cultural contexts, then practice will emphasize human agency, action, and emancipation. A Kuwaiti physician, also Arab, Muslim, and female, exclaimed that ―a lot of people don‘t see that the way they speak about this issue is an issue‖ when discussing the

Ministry of Health‘s goal to segregate healthcare based on nationality in Kuwait: ―I‘m talking about people who are educated, in my surroundings [i.e., physicians]… Who go to Switzerland every summer [and] think this [segregation] is not racist‖ (P-11: 137-142).

As we saw earlier, the Western world is used as a benchmark for technology, innovation, and even mental health ethics since Western psychology has been very successful in terms of academic growth, professional development, and even global expansion (Huygens, 2009; Teo,

2009). However, success and expansion do not necessary translate to ethical practice. For instance, three Arab female clinicians felt that ―dual relationships‖, which are highly ―frowned upon‖ in the APA code of ethics, may be unavoidable and also beneficial in Kuwait because they

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reduce the doctor-patient ‗power gap‘ as long as privacy and confidentiality are not breached.

One physician was angered by the fact that her boss forced her to terminate therapy with someone she had a dual relationship with even though this was not in her patient‘s best interests, and therefore deemed unethical to her. Therefore, it is recommended that clinicians remain flexible with regards to dual relationships: ―be more sensitive to what‘s going on in the culture…

Bend it to what the people want‖ (P-4: 2369). This also becomes important when attempting to understand religious healing practices and what many practitioners refer to as ―psychosomatic‖ experiences, which are addressed below.

Understanding shamanism and somatization. There has been a general assumption that industrialization and modernization would wipe out traditional or indigenous folk beliefs and healing practices, however this is not true in Kuwait or worldwide (Azaizeh, Saad, Cooper, &

Said, 2010; Singer & Baer, 2012). Much like other regions throughout the world (e.g., South

Asia, North America, and Australia), this study demonstrated that Kuwait is embarking on what medical anthropologists would refer to as medical (rather, mental health) pluralism, or having multiple approaches of caregiving co-existing either cooperatively or in open conflict (Singer &

Baer, 2012). Based on Chrisman and Kleinman‘s (1983) extensively used model for pluralistic healthcare, there are three major sectors of caregiving systems: (1) the popular sector, comprised of individuals who heal themselves in conjunction with their social networks, families and communities (i.e, the ―therapeutic management group‖); (2) the folk sector, made up of independent caregivers such as shamans, religious healers, hypnotists, or psychics, who are either self-trained, apprenticed, or appointed by religious governing bodies (e.g., the church or mosque); and (3) the professional sector, which is made up of healthcare practitioners operating within clinics, hospitals and healthcare associations. According to Fabrega (1997), state

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societies, such as Kuwait, help construct idioms of health and illness within two tiers: (1) an elite system of scholars, medical professionals (e.g., the MEPA and KPA) and their advocates; and (2) a variety of less academically prestigious ‗physicians‘ (e.g., non-accredited practitioners) and folk or religious healers (sheikhs and imams).

Arthur Kleinman and other physician-anthropologists have spent their academic and professional careers gently reminding other physicians to not only listen to what their patients are saying, but also how they communicate their distress (e.g., Kleinman, 1988; Singer & Baer,

2012). This involves the understanding that suffering is not merely an individual experience of events that is expressed through our cognitive framework, but also ―articulated through emotionally charged cultural metaphors and themes‖ (Singer & Baer, 2012, p. 87). This is particularly relevant in the cases of using jinn, demons or monsters to describe suffering, for which some people will seek out sheikhs, imams, or other folk healers to help exorcise or temper them – or at the very least, provide meaning behind their suffering. These idioms are, more often than not, what anthropologists, sociologists and other scholars refer to as ―embodied human experiences‖, or ―experiencing the world within the confines of our bodies‖ (Singer & Baer,

2010, p. 100). In other words, they argue that our bodies – opposed to our minds – are the primary site of our experiences, and this seems to be particularly true in societies such as Kuwait that have external explanatory models for illness and embrace folk traditions. For example, some people may genuinely feel that they are succumbing to these invasive forces or beings in their bodies. Many clinicians felt that their more ―traditional‖ or ―non-Westernized‖ patients (or

―clients‖ if they were therapists) are more likely to present emotional pain ―somatically‖ rather than ―mentally‖, and use several cultural metaphors – jinn being the main one – to describe their suffering. While ―jinn‖ and the ―evil eye‖ can be idioms to describe the source of persecutory

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delusions seen with schizophrenia, for which medication may be helpful, others use it to describe what some practitioners would normally characterize as depression or anxiety ―with somatization‖.

Not surprisingly, many patients (who some call ―hypochondriacs‖) who seek a medical explanation for their pain can go through several ―unneeded‖ medical investigations – most of which are said to be inconclusive, or suggest that the patient is ―perfectly healthy‖. Some practitioners even felt that psychotherapy made their symptoms of pain dissipate over time, and told their patients that they suffer from depression or anxiety, perhaps stemming from their family environments, and that they are having ―psychosomatic‖ experiences. When referred to psychotherapists or psychiatrists by their family physicians, however, most patients often decline and demand to be treated by their family physicians instead, who are often too burdened to provide more than a brief psychotherapy or CBT session (if they are generous with their time) or a prescription for mood stabilizers, antidepressants, or anxiolytics. Neither treatment approaches are, according to some clinicians, a ―specialty‖ for family physicians who have, at best, limited training in psychotherapy and psychiatry. Frances (2013) also noted that approximately 80% of the prescriptions for psychoactive drugs are written by primary-care physicians in the United

States – a trend that may be occurring in Kuwait as well according to anecdotal evidence; however there are currently no statistics to verify this.

Some clinicians in Kuwait attribute the over-reliance on family physicians to the stigma associated with being mentally ill or seeking mental health care; however anthropologists and sociologists (such as Irving Zola) would argue that they fear their external metaphors for distress

(or their ―stories‖) are being undermined and invalidated through the medicalization (or

―mentalization‖) of their experiences (Singer & Baer, 2012). This also explains why some

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Kuwaiti patients will revere family physicians who listen to them, understand their life stories, and are a part of their communities. It also explains why physicians can have extreme difficulty in convincing some of their Kuwaiti patients to take psychoactive drugs. For a culture in which people largely feel that their distress is caused by external forces (jinn or the ―evil eyes of others‖), persuading them that it is ―all in their minds‖ is misinformed and negligent if it causes further distress because it essentially puts the onus of distress on the individual, rather than on many of the societal problems that plague Kuwait. On the other hand, when seeking folk therapies, some people can be subject to extreme medieval practices (described by two participants) such as bloodletting or chemical burning which can be even more traumatizing and highly dehumanizing and unethical. Therefore, many have little choice but to seek care through their families and communities, or remain isolated from the rest of society, living with the constant fear that their bodies have been inhabited by evil forces. Some may even live with the guilt that they are not religious enough and feel that they are being punished (AlHomaizi &

AlHomaizi, 2014). After speaking with a physician, they can feel that their minds are clouded owing to their own negative thoughts which need to be ‗fixed‘. This calls for the introduction of narrative medicine (discussed below) into Kuwaiti healthcare, which bridges the gaps between the type of story-telling (and story-listening) that occurs with interpersonal therapy (IPT), the honouring of spiritual and religious beliefs that occur with religious healers, and modern medicine.

Ancient Muslim Caregiving Practices

The one thing that Hippocrates, Checkov and Freud all had in common was that they were all physicians who embraced the care provider-care receiver relationship as one of story-telling and story-listening – a tradition that has been relatively obscured by modern medicine (Charon,

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2005). With narrative medicine, which is essentially what some primary care physicians are already practicing in Kuwait, patients are asked to share their experience of suffering: ―your suffering is true, and I know how it‘s difficult to have this pain. But no need for all these investigations; all you need to do is express [yourself]‖ (P-14: Islamic family physician, female,

58-60). And she listened. She later discussed the importance of taking her patients‘ life histories, being a part of their communities and helping them draw parallels between their difficult life events and trips to the hospital, which she felt was a very cathartic and enlightening experience for her patients and went a long way in easing their suffering. What this family physician described resonates very strongly with the Hippocratic notion of knowing the patient, rather than the disease (Singer & Baer, 2012).

The underlying goals of public healthcare in Kuwait – that many physicians, particularly those involved in palliative care, embrace (e.g., Al Saleh et al., 2015) – also resonate with ancient Muslim caregiving practices. These practices were largely based on Persian, Greek,

Indian, Jewish, and other neighbouring regions‘ religions, philosophies and practices that set the standards for medicine in the Middle Eastern region about 1,500 years ago (Miller, 2006). In addition to education, training, the importance of keeping medical records (i.e., the patient‘s

―story‖, which was largely based on Hippocrates‘ teachings), legislative oversight to enforce ethical practice, these standards also included universal healthcare to everyone regardless of creed, nationality, gender, or status in the community (Miller, 2006). Essentially, public primary care facilities (in addition to psychiatric services) in Kuwait are predicated on these values because they are indeed accessible to everyone who lives in Kuwait (including Bidoons,

Bedouins, and foreign workers). Unfortunately, as we saw in many of the clinicians‘ narratives, these ancient practices have been somewhat obscured by the effects of global medical discourses,

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privatization, and what Frances (2013) would call, ―the medicalization of ordinary life‖.

Therefore, the argument here is that Kuwaiti mental healthcare needs to resurrect some of the ancient interdisciplinary principles and practices of care that governed much of the Muslim world prior to the globalization and the diffusion of Western categories of illness and disease, and refrain from labelling people‘s experiences in an attempt to de-stigmatize them and improve access to services; we will see below how this can be more harmful in the long run.

De-stigmatizing Mental Healthcare and Mental Illness in Kuwait

Every society stigmatizes people with mental illness and those who treat them, in varying degrees (AlHomaizi & AlHomaizi, 2014; Corrigan, 2007). Echoing Frances‘ (2013) arguments regarding the stigma of mental illness, it is bad enough to receive a ―label‖, or a ―mark‖, to feel

―abnormal‖, or ―rejected‖ from a society for not satisfying the mental, emotional, and behavioural (i.e., moral) standards set by that society. However it is even worse to be mislabelled with a diagnosis because there are absolutely no recourses for this – a ―dead loss‖, if you will – especially in a society such as Kuwait, where stigma can be more crippling than it is in the West

(AlHomaizi & AlHomaizi, 2014).

Virtually every participant felt that mental illness and mental health services need to be de-stigmatized in Kuwait for the purpose of reducing shame and providing adequate care to those who would otherwise go untreated. The classic example that supports both de-stigmatization and the need for psychiatric services in Kuwait was given by Participant 7, who provided an emergency intervention for parents whose adolescent son was patrolling the house with a loaded gun, claiming that he was going to be attacked. Since his parents were initially ashamed to seek mental health services for him, his behaviour escalated and the therapist established that he was

―not connected to reality‖ and a danger to both himself and those around him. Cases like these

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require immediate legal and psychiatric intervention (e.g., restraint), in addition to social work and/or psychotherapy. Perhaps if mental illness was less stigmatizing in Kuwait, his parents would have sought care much earlier rather than isolating him at home. However, much of the stigma associated with mental illness and mental healthcare is owing to participants‘ negative experiences with the mental health sector (Scull et al., 2014) and what appears to be genuine resistance towards these services – particularly in terms of ―labels‖ and psychotropics.

Public discourse on de-stigmatization has already begun in Kuwait. One of most notable efforts are by two Kuwaiti sisters, Dalal and Alaa AlHomaizi, who are pursuing careers in clinical psychology and gave a Ted Talks at Columbia University in 2014, publically challenging the stigma against people with mental illnesses in Kuwait, as well as the stigma against those who treat them (AlHomaizi and AlHomaizi, 2014). They coined the term ―psylence‖ to denote the stigma, shame, and secrecy that is often associated with mental illness in Kuwait.

Additionally, recent efforts to demonstrate to psychology undergraduate students that the caregiving practices at the Kuwaiti psychiatric hospital are ethical and equitable, are also reflective of the de-stigmatization efforts in Kuwait (AUK, 2015). Finally, several researchers and other members of the Kuwaiti community, myself included, have recently published articles in academic journals, supporting the de-stigmatization of mental illness and mental health services in Kuwait. What‘s worrying, however, is that there is little open discussion about many of the bioethical risks associated with de-stigmatizing mental illness and the mental health profession. The following section discusses these risks (which appear to be occurring already), and how they can be mitigated.

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Bioethical Risks associated with De-stigmatization, and how to mitigate them.

Being able to enlist the confidence and hope of the sick patient has always been

and still is the most essential skill in a great shaman or a great modern doctor.

(Frances, 2013, p. 99)

The quote above demonstrates that being labelled as ‗sick‘ is, unfortunately, a necessary precursor to healers inspiring hope and confidence in those are labelled as sick. Patrick Corrigan, who is regarded as an expert on stigma research, argues that diagnostic labels actually worsen the stigma of having a mental illness; that even in countries where mental illness has less stigma than

Kuwait, those with more serious mental illnesses (such as schizophrenia) are not more likely to engage in therapy than those with less serious ones. Additionally, in terms of major depression and suicide, anti-stigma campaigns only contribute to minor improvements in public knowledge and awareness about mental illness. However, no research, according to Dumesnil & Verger‘s

(2009) review, demonstrates increases in mental health service utilization for serious mental health issues, or decreases in suicidal behaviour – much like anti-drug campaigns do not decrease substance use, but may in fact encourage it (Hornik et al., 2008). Anti-stigma campaigns can, however, increase in the influx of well-informed (rather, misinformed) consumers, who begin to self-diagnose and feed emotional hypochondriasis (Applbaum, 2006;

Frances, 2013). This has been reported in Kuwait (as it likely is in any country): two of the physicians I interviewed (one psychiatrist and one family physician) felt that many of their patients are ―hypochondriacs‖ and ―malingerers‖ who do not warrant diagnoses or medication.

Pharmaceutical drug marketers play a crucial role in influencing care practices

(Applbaum, 2006; 2009; Frances, 2013). Likewise, care providers and researchers play a crucial role in producing and disseminating this knowledge (discourse) and influencing healthcare

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practices (Danziger, 1997; Flynn, 2002). Similarly, public mental health advocates and consumers are easily influenced by both pharmaceutical companies, care providers, and other mental health advocates, therefore the odds are stacked against consumers, in particular, in thinking critically about mental health and illness because they are consistently bombarded with messages of ―illness‖ and ―hope‖ from the mental health sector (Frances, 2013). One therapist even expressed that mental health professionals are more capable of being ―neutral‖ and

―unbiased‖ and suggested that they are better able to provide support than alternative sources such as religious healers, family members and family physicians (e.g., P-1: 580-582). The healing ritual provided by mental healthcare, therefore, can become promising for individuals who want to rid themselves of ―maladaptive behaviour‖ or an ―illness‖ in order to be a valued member of their community (Frances, 2013). This appears to be more pronounced in Kuwait since the ‗doctor‘ title is extremely respected – possibly more so than it is in the West; some therapists even felt that many Kuwaitis don‘t like ‗egalitarian‘ treatment: ―I‘m paying you to tell me what to do‖ (P-4: 1253-1349).

As Arthur Kleinman reminds us, despite the necessity for psychiatry and other mental health services in any effective healthcare system, and as Vickery (2010, p. 366) succinctly articulates, it ―brackets psycho-social, political, and economic factors out of the clinical gaze‖, essentially brainwashing mental health professionals and the general public ―to see mainly one slice of a broader spectrum‖, like Foucault (1965) predicted. Likewise, Applbaum (2009) reminds us that patients and other mental health consumers feel ―empowered‖ when the decision making regarding their mental health plan appears democratic. ―Democratic‖ mental healthcare involves ―shared decision-making‖ which is only possible if a consumer‘s perceptions of mental health and illness largely echo those of the individuals who provide these services. The most

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crucial step in changing the way consumers (current and potential) think about mental healthcare, including prescription psychoactive drug use, is by de-stigmatizing (i.e., socially marketing) mental healthcare and mental illness. Therefore, anti-stigma campaigns are a ―happy example for the pharmaceutical industry‖ because they demonstrate – however misguidedly – that the public is on the same ideological page as the mental health and medical industries (Applaum, 2009, p.

118).

Iatrogenesis and the “worried well”. In Greek, the term iatros means ―healer‖ and genesis means ―brought forth by‖, therefore the literal definition of iatrogenesis is ―brought forth by the healer‖, and is typically used to describe the negative health outcomes on patients, brought forth by their care providers (Palmieri, Peterson, & Ford, 2007, p. 19). Several participants in this study felt that Kuwait is an over-medicated society, owing to the over- diagnosis (rather, misdiagnosis) of mental disorders, such as anxiety, depression, and ADHD, for which the first course of action once a patient enters public healthcare facilities is a prescription.

The only study fully addressing iatrogenic (i.e., physician-induced) drug dependence in Kuwait was carried out in 1989 by A. M. Bilal, a Sudanese psychiatrist in Kuwait, who pointed out, that after intravenous fluids and vitamins, the primary drugs given at a local psychiatric facility were benzodiazapines and neuroleptics (e.g., haloperidol and thioridazine) for the detoxification of patients who were already suffering from addictions (Bilal, 1989). According to his analysis, there was a shift between the use of illicit substances – which even today are primarily alcohol, heroin, hashish and amphetamines – to benzodiazapines: ―iatrogenically propagated dependence on benzodiazapines has to a large extent superseded addiction to illicit drugs and alcohol in this country‖ (Bilal, 1989, p. 1138). This makes sense; drugs such as Xanax, Valium and Librium are highly euphoric and sedative in nature – anyone experiencing difficult life circumstances, or

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merely want to escape from the humdrum of everyday life – can obtain a prescription from their primary care physicians if they seem anxious enough. However, they are highly addictive, and withdrawal anxieties, including severe panic attacks, are usually more severe than when the patient first started the medication, and their overall emotional and physiological effects do not outweigh their medicinal benefits and can actually lead to more overdoses and deaths in a population (Charlson et al., 2009; Frances, 2013).

In Kuwait, however, Bilal (1989) also noted that ―this label [iatrogenesis] is not entertained by psychiatrists in this setup‖ (p. 1138), making the resurrection of his arguments all the more necessary, especially given that there are no recent statistical reports on the patterns of iatrogenesis in Kuwait and their impact on emergency room visits and drug-induced deaths. The lack of statistical reporting as well as the over-prescription of psychotropic drugs, may be due, in part, to the lack of resources at the psychiatric facility in Kuwait (however, we cannot overlook the possibility that some physicians may be denying their role in contributing to iatrogenic suffering). According to a Kuwaiti psychiatrist, who expressed contempt towards the organizational structure of the psychiatric and public administrative health services in Kuwait,

If you compare the level of psychiatric services in the outpatient [department]

here, to let us say the modern world level of outpatient psychiatric services, we

are way below the accepted standard of care. We are way below. We need so

much effort to – to correct it or to bring it up to the optimum level… But we don‘t

have the resources for that... For follow-up (treatment) I only have five minutes to

make sure that safety is there regarding suicide, homicide, and safety using the

medication, and what‘s the long-term plan for the medication… [All] we can do

in the five minutes [is] we can give them the medication… [To see] if there is any

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other option apart from pharmacotherapy, but we have limited psychotherapy (P-

10: Psychiatrist, 405-415).

Given that many psychiatrists are limited to ―five minute sessions‖ per patient, and the general lack of ―other modalities for support‖ such as psychotherapy and social work, it is difficult for psychiatrists to do anything other than write a prescription and make sure their patients are not an immediate and active threat to themselves or those around them, creating a very high-pressured work environment. According to my interview with another psychiatrist, individuals – particularly young adults – may resort to misusing prescription psychoactive drugs because other substances, such as alcohol, are illegal and often too toxic (e.g., ethanol): ―I remember seeing a patient in the ER, he was in his early 30‘s. He‘s an alcoholic and he was having severe hematemesis… vomiting blood because of a liver problem, secondary to his alcohol [addiction]‖ (P-8: 1378-1399). Therefore, given that benzodiazapines are often used to treat alcohol addiction and withdrawal as part of a ―detox‖ regime, iatrogenic drug dependence may also be attributed to pre-existing addictive behaviour and patient misuse of prescription drugs.

What makes matters more complicated in Kuwait is that illicit substance use is highly frowned upon and also illegal according to Islamic law (AlMarri & Oei, 2009), leading to an interesting paradox: while illegal substances are still widely used and stigmatized, prescription drug use is almost accepted by the sheer fact that they are administered under the legal umbrella of modern medicine. Therefore, as Frances (2013) notes, ―when their products are used carelessly, the drug companies can be as dangerous as the drug cartels‖ (p. xv). Considering that

Bilal‘s (1989) study was carried out almost two decades ago, and given participant reports on the over-prescription of psychoactive drugs, there is reason to believe that Kuwait is following in the

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same footsteps as North America where prescription drugs can account for at least four times the number of emergency-room visits and overdoses than illicit drugs (Center for Disease Control and Prevention [CDC], 2011). In Florida, for example, the death rate owing to prescription psychoactive drug use increased by 84% between 2003 to 2009 (CDC, 2011).

The preceding passages suggest that even in countries that are perceived to be following the ―accepted standard of care‖ in the ―modern world‖, where seeking mental health services is relatively less stigmatizing, there is a general lack of oversight on how drugs are prescribed. In the United States, most research trials fail to show significant differences between antidepressants and placebos, and suggest that the highest responses to the placebo effect occur among individuals with mild to moderate depression – or the ―worried well‖ – who would normally get better on their own, with time (Fournier et al., 2010; Frances, 2013; Kirsch, 2009).

Some physicians I interviewed in the current study expressed some dissatisfaction with the side- effects of prescription psychoactive drugs, as well as their over-prescription and misuse, however not a single person I interviewed even mentioned the placebo effect. Given that psychiatric practices in the U.S. are considered to be the ―gold standard‖ for medical care in Kuwait, it is important for the Kuwait mental health sector and public to be mindful of how drug manufacturers receive approval by the Food and Drug Administration (FDA). According to

Kirsch (2009), the FDA requires ―two adequately conducted clinical trials showing a significant difference between drug and placebo‖ (p. 321); therefore, the loophole is that the number of clinical trials that demonstrate negative results do not count for approval.

Primary care taking over psychiatry? It is evident that some primary care physicians in

Kuwait are beginning to provide interpersonal therapy and cognitive behavioural therapy after receiving brief training sessions (including online). However, there are no reports to verify the

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percentage of psychotropics that are prescribed by primary care physicians versus psychiatrists.

However, given that it is more socially acceptable to see primary care physicians in Kuwait, as well as the fact that they are more accessible, there is reason to believe that primary care is taking over psychiatry – a phenomenon that has been discussed at length in North America

(Frances, 2013; Hodges, Inch, & Silver, 2001; Horvitz-Lennon, Kilbourne, & Pincus, 2006;

Unützer, Schoenbaum, Druss, & Katon, 2006). Even the WHO (2008) characterizes primary care as an essential component of any healthcare system. Between 1950 and 2000 in the U.S., primary care physicians were the first point of contact for patients, and the majority of people who were treated with psychotropic medication were under the care of their primary care physicians, rather than mental healthcare providers since the stigma of being ―labelled‖ can be a deterrent for seeking psychiatric services, even in the U.S. (Hodges et al., 2001). This trend has continued recently since most primary care physicians are prescribing psychotropics: 87% of anxiolytics,

79% of antidepressants, 66% of stimulants (including ADHD medication), and 51% of antipsychotics (DuBosar, 2009). Mild to moderate mental health issues related to anxiety, depression, and attention-deficits, usually go away on their own, or with the help of general counselling without the use of any medication at all, however patients and their physicians often misattribute this ‗recovery‘ to the medication rather than natural human resilience (Frances,

2013).

The irony in all this is that primary care physicians do the majority of diagnosing and prescribing, but are not placed in the general hierarchy of mental health diagnosticians, which generally goes as follows: 1) psychiatrists; 2) psychologists; 3) psychiatric nurse-practitioners; 4) social workers; and 5) counsellors (Frances, 2013, p. 233). This hierarchy is not reflective of ability, since, in some cases, some of the best diagnosticians have been social workers, while the

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worst have been psychiatrists (Frances, 2013). Given their general lack of training in providing therapy or making diagnosis – let alone the limited amount of time they have to spend with each patient – we need to ask the critical question, should primary care physicians be ethically allowed to make mental health diagnoses and prescribe psychiatric medications? This requires some debate in Kuwait that goes beyond the scope of this research, especially given that there is no published data on the prescription patterns at primary care facilities. The WHO (2008), however, strongly advises primary care physicians to obtain the skills and training necessary to provide mental healthcare. On the other hand, Frances (2013) reminds us that primary care physicians are generally underpaid, overworked, and have minimum training in psychotherapy and psychiatry, therefore convenience (i.e., writing a prescription) will often trump good care.

Future research and mental health conferences in Kuwait would do well to address these issues.

Even the most distinguished of critics who argue that pharmaceutical companies, via the mental health domain, are disseminating ‗American‘ knowledge products and pathologizing cultural differences across the globe, praxis is an issue. In other words, these criticisms generally lack a discussion on genuine alternatives that can counteract the issues and cultural deficits they identify (Harrist & Richardson, 2014, p.201). Allan Frances, however, has provided some insights as to how scholars, educators, care providers and the general public can counteract disease mongering, diagnostic inflation, iatrogenesis, and drug company propaganda, which is not only applicable in North America, but also globally (Batstra & Frances, 2012; Frances,

2013). These strategies are outlined below.

Diagnostic Deflation. Owing to the ―diagnostic inflation‖ of mental disorders that has occurred, world-wide, it only seems logical that the next step would involve attempts at taming this inflation to hopefully reach a point of ―diagnostic deflation‖ (Frances, 2013). This is more

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complicated than it sounds, as most political and financial sectors are ―pushing abnormal‖ (i.e., the thesis side of the dialectical model), while the forces to counterbalance this have limited power (i.e., the antithesis side of the dialectical model). Although many doctors are responsible in their prescribing (such as the one described by Participant 26, who was gently withdrawn from his anxiolytic medication), there are always a few ―bad apples‖ who get away with irresponsible drug promotions and prescribing. They are usually (but not always) the ones who are highly regarded in their communities, have a string of academic degrees and qualifications from prestigious universities, are constantly attending drug company events, are funded by the NIH or pharmaceutical companies for their ―high-calibre research‖, and are regarded as ―experts‖ in their areas of specialty (Frances, 2013).

Diagnostic deflation involves several counterbalances, which include a ―push‖ against these so called ―experts‖, and are outlined by psychiatrists (Batstra and Frances, 2012; Frances,

2013) and psychologists (Wade, 1997). On the diagnostic front for issues that do not require urgent legal or medical intervention, this involves ‗tightening‘ the criteria of diagnostic evaluations by using a ―stepped‖ diagnostic procedure by: (1) taking time to gather baseline data about the service user (i.e., life history); (2) validating, but normalizing their issues as expectable responses to daily hassles; (3) watchful waiting – i.e., continued (or introducing) psychotherapy or social work with no intention of providing a diagnosis or active medical treatment; (4) encouraging minimal interventions (e.g., books, self-help therapy); (5) continued counselling; (6) if required, a definitive diagnosis and treatment. Wade (1997) highlights that helping individuals

– particularly those who have been subject to oppressive or authoritarian treatment from other people – realize that their perhaps deviant behaviours are quite natural, and valid responses to resist disempowerment, can go a long way in helping them find ways to negotiate their

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autonomy. The findings of this study support this method because those who practiced the skills of negotiating, rather than asserting their autonomy (which tends to backfire in Kuwait), tended to be more culturally integrated and demonstrated more personal agency. These methods are more direct, efficient, and, most importantly, they take advantage of the ―powerful healing effects of time‖, support, and natural human resilience (Frances, 2013, p. 222). This method, commonly employed by counsellors and clinical social workers (and some vigilant physicians and psychologists), is cost-effective because it ultimately separates those who genuinely require a diagnosis and medication, from those who will recover, and may even do better, without a diagnosis and active psychiatric treatment.

Counteracting drug company propaganda. As part of diagnostic deflation, Frances

(2013) also recommends what critically-oriented scholars have doing in their fields: pushing against drug company propaganda (e.g., Marecek & Hare-Mustin, 2009). The three groups that can accomplish the push against disease mongering are the same groups that help reinforce it: professional organizations (including hospitals, clinics, psychological and psychiatric associations), consumer advocacy groups, and the media. However, none of these groups in

Kuwait (let alone North America) have been publically invested in fighting these social marketing efforts, largely owing to the fact that they are co-opted by drug marketers.

Professional mental health associations (in Kuwait, this means the MEPA and KPA) also seem passive in the face of psychiatric misdiagnoses and their iatrogenic effects in Kuwait. Therefore, as part of their efforts to increase ―ethical service delivery‖ these associations need to give voice to the narratives of resistance towards mental healthcare that have been outlined in this study and take responsibility for informing the public on these issues to validate, rather than suppress, the

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critical thinking – i.e., being a ―smart consumer‖ – that is already permeating much of the

Kuwaiti public.

On the marketing front, one very prominent North American psychologist in Kuwait, was highly supportive of marketing ―basic health things‖ such as ―ADHD‖ and ―depression‖ in

Kuwait. This practice should not be supported by Kuwait‘s Ministries of Health, Education, and

Social Affairs because it is supports the same direct-to-consumer advertising that is directly implicated in diagnostic inflation and iatrogenic deaths in North America and Europe (Frances,

2013). This involves a serious pushback (and perhaps auditing system) from the Kuwait Ministry of Health – i.e., a commitment to not accepting (or allowing physicians to accept) drug company- sponsored promotions and ―continuing education‖ events for physicians and students.

Additionally, doctors should not be allowed to accept ―free samples‖ from drug marketers.

Anecdotal evidence from my time in Kuwait suggests that Pfizer (and perhaps other companies as well) is already digging their claws into private health clinics employing general practitioners; therefore the Ministry of Health should take responsibility to audit these marketing efforts.

Finally, no mental health consumer advocacy groups in Kuwait should be allowed to receive financial aid from foreign drug marketers (either directly or indirectly via local agencies).

Currently, the Kuwait Foundation for the Advancement of Sciences (KFAS) is run by small taxes paid by private corporations in Kuwait to fund research and education in the sciences and humanities; they should be a part of the effort to counter drug company propaganda, rather than fund studies and education/advocacy groups and associations that support it. I strongly agree with Frances‘ (2013) contention that mental health organizations have the power to change, ―if their incentives are aligned with public interest‖ (Frances, 2013, p. 224). The only question is whether or not they will do it. The next ssection takes Frances (2013) arguments further by

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demonstrating how Kuwait‘s mental health sector can align themselves with actual public interests in Kuwait.

Conclusion: Increasing the Momentum of Social and Political Reform in Kuwait

The aspect of political culture that is most relevant to democratization is mass aspirations for

freedom – and if a given public emphasizes these values relatively strongly, democratization is

likely to occur (Welzel & Inglehart, 2005, p. 81)

Upon speaking with a licensed clinical social worker and counselling psychologist, Nicholas

Scull, it is evident that the ―cultural diversity and social justice‖ sections of the American

University of Kuwait are supporting social and political reform with foreign workers by teaching them qualitative research methods and engaging them with the local community. In a recent email, he said:

We developed a service learning project where students were tasked with

interviewing a foreign worker asking about their life and experience moving to

and working in Kuwait (e.g., life history, why they moved, what they left behind,

working conditions, hopes for future, etc.). With their permission, they had to

write a first person summary of the person's life. They used first person in order to

better take the participant's experience. Then, based on what they identified was

the person's biggest struggle, they developed an online campaign to raise

awareness (e.g., low wages, physical abuse of workers, poor housing conditions,

poor access to health care, etc.). The vast majority of students report that the

project radically changes the way they see foreign workers ("I always thought that

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they were lucky to come to Kuwait"). (N. Scull, personal communication, August

2016)

Not only does this exercise promote more emancipatory research methods, it also demonstrates how interacting openly with foreign workers by asking them about their lived experiences can illuminate people about the bureaucracy and structural impediments that negatively affect foreign workers in Kuwait. As Welzel and Inglehart (2005) contend in the quote above, and as demonstrated by my research, Kuwait is experiencing a post-materialistic shift since young adults, in particular, are beginning to embrace these ―mass aspirations for freedom‖ (p. 81). Additionally, as we saw earlier, some physicians and humans rights advocates are beginning to advocate for foreign workers. Welzel and Inglehart‘s (2005) research supports

Marx‘s predictions since it demonstrates that economic development, which Kuwait has experienced quite rapidly, contributes significantly to the emergence of more democratic governments – particularly when large masses of people begin to revolt – either actively or passively – against oppression. Therefore, these liberty aspirations need to be given public voice.

The Kuwait Society for Human Rights, for example, is a non-governmental organization (NGO) that is quite active in their attempts to promote and protect human rights in Kuwait, and are seeking community members to get involved. The Kuwait mental health sector can avoid the same ridicule that the mental health sector in the United States is experiencing right now (and has been for the last century) by de-emphasizing the need for psychological testing and psychopharmacology, and aligning itself with more progressive movements of resistance, social justice, and human rights. This is a core idea in many of the subdivisions of psychological associations in the United States (e.g, APA‘s Division 32: Society for Humanistic Psychology),

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critical psychology and sociology that should be given voice in Kuwait. This view of an activist, partisan psychology is a radical alternative to the so called ―neutral‖, ―objective‖, and

―scientific‖ endeavors of much of mainstream psychology and psychiatry – which we have seen, are not always neutral, objective, or scientific. Even the scientific research in the field of psychology and psychiatry that support more critical and culturally-nuanced alternatives to mainstream methods are often silenced or exploited for marketing purposes. The arguments put forth by Evans & Loomis (2009), Steinitz and Mishler (2009) and Reicher (1996), outline how mental health theory, research, and practice can be reconceptualized in ways that honor psychology‘s and psychiatry‘s fundamental purpose to understand and stand against the political structures that maintain human suffering. These authors‘ ideas inform the following initiatives that will, hopefully, contribute to lowering Kuwait‘s rank as one of the world‘s worst countries for endorsing human rights violations.

As recently highlighted by social work advocates in Kuwait (e.g., Almazeedi &

Alsuwaidan, 2014; Kaladchibachi & Al-Dhafiri, 2016), psychiatrists, family physicians, and psychiatric nurses significantly outnumber social workers, who make up less than 2% of the manpower at public mental healthcare facilities. This is highly problematic because psychiatric outpatient centers are also responsible for providing services to the main regional hospitals as well as prisons and special education schools. Essentially, this means that they are overworked and resorting to handing out medication rather than dedicating valuable time and resources to challenging the bureaucratic structures that maintain oppression and inequality in Kuwait. Rather than focusing specifically on managing illnesses, in the long run, the mental health sector will have a lot more positive impact in the Kuwaiti community by bridging gaps between themselves and both governmental and non-governmental, community organizations. Mental health

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professionals have, historically, been involved in mobilizing resources to make positive community changes. The psychiatrists and psychologists who worked with the LGB community in the United States to have homosexuality removed from the DSM III is a classic example of the power mental health professionals have when they work directly with oppressed communities to challenge injustice (as we saw in Chapter II). Similarly, care providers in Kuwait, who are often highly critical of corruption and injustice, can increase their emancipatory potential by mobilizing different community, legal, educational, and administrative forces to promote social justice.

First, this requires an abandonment of the ‗silos mentality‘ through which most health, community, and public administrative services are fragmented. In other words, this calls for bridging the gap between mental healthcare and the Kuwait Society for Human Rights, and acting to collectively push the Kuwait Ministry of Education to de-emphasize the importance of more traditional degrees (e.g., engineering and business), and instead begin to subsidize degrees related to the humanities and social work, and publically encourage them. One mental health advocate felt that psychology should be a separate discipline, even though the Ministry of

Education has grouped it with sociology and anthropology; this should remain as it is. Separating psychology as a scientific and clinical discipline and segregating it from the humanities will only act to fragment psychological theory, research, and practice in Kuwait and diminish its interdisciplinary power. Second, mental health professionals and primary care physicians can give voice to the budding feminist movement in Kuwait and increase public discourses related to many of the problematic patriarchal practices that reinforce the physical and sexual abuse of women and children. For example, mothers need to have equal rights to guardianship as fathers in Kuwait. Seeing as those in primary care (e.g., OBG/YNs, paediatricians, and family

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physicians) may be the first to witness abuse and can legally document its evidence (including in foreign workers), primary care physicians need to be the bridging gap between Kuwait‘s forensic and law-enforcement sectors and the Kuwait Society for Human Rights in order to push the

Kuwaiti government to grant women these rights. Seeing as physicians (or therapists) acting alone have no power against the law in Kuwait (since a dominant male relative‘s words carry more weight in court), it is imperative that they work with different sectors to raise awareness about their rights to press charges against those who physically and sexually abuse them; this right needs to be extended to foreign workers as well. It is also equally important for children to be able to report abuse in their schools, after which counsellors need to mobilize the resources to advocate for them. Third, foreign embassies that deploy domestic workers (e.g., from India,

Nepal, Bangladesh, and Ethiopia) would do well to train and hire teams of social or case workers from their own countries to work in Kuwait and be the first points of contact for them. These embassy-appointed social workers need to have an open line of communication between domestic workers and their employers to ensure that they are not being abused. In the event that a ―sponsor‖ is accused of committing a human rights violation (including the ―buying‖ or

―selling‖ of another person), they will need to be flagged, investigated, and, if necessary (which will most often be the case), banned from sponsoring foreign workers in the future. This will require the collective effort of foreign embassies, Kuwait‘s Ministry of Foreign Affairs, the

Kuwait Human Rights Society, local law enforcement and, most importantly, healthcare providers who are trained to assess and document abuse.

As noted by Teo (2009), ―theorizing for the sake of theorizing and research for the sake of research‖ are ―indulgent practices‖ and must be considered indulgent practices given that lives and deaths are at stake. Care providers are fully aware of the social and psychological toxicity

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that accompanies inequality and oppression. Therefore, standing passively by on the sidelines is the very thing that will continue to keep the mental health discipline stigmatized and ridiculed by the public.

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Reflexivity

There were two critical moments that shaped my writing since I first began this research project.

The first was my meeting with a young Kuwaiti man, a few years younger than myself, who gently reminded me about the importance of charity and humility in Islamic cultures during his interview. The second was the realization of how personal traumatic events from my childhood drove my interests in the study of power in healthcare settings. Another thing that I found particularly interesting was my role in this research as a North Indian who was born and raised in the Middle East, spent nine years in Canada, and was studying mental health and illness in a country in which I am both an ‗insider‘ and an ‗outsider‘. This certainly impacted my research, from data collection to analysis.

I remained reflexive, perhaps overly so, throughout this research. The only thing that recently hit me, as I was writing my final chapter, was that the only reason I may have heard

―anti-American‖ and ―anti-Arab‖ narratives during the interviews is because people do not identify me as American or Arab. When participants asked where I was from, and I said ―India, but born and raised in the Middle East, currently studying and living in Canada‖, I was identified as ―Indian‖. So I got the pleasure of hearing very deep, honest perceptions about cultures that were not my own, because my participants did not want to risk insulting me. It was an act of courtesy. Discourse analysis requires us to listen to not only what is said, but also what is not said. Not once, did anybody put down low-income foreign workers from the Indian subcontinent, even though many said that they are discriminated against, by ―other‖ people. Even when listing the nationalities of domestic workers, who are often viewed as a burden in healthcare settings, people were careful not to say ―Indian‖ even though people from the Indian subcontinent (including Pakistan, Sri Lanka, Bangladesh and Nepal) make up the majority of

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foreign workers. Had I gone in as an Arab, I may not have heard a lot of orientalist perspectives; had I gone in as an American, I may not have heard some of the anti-American discourses, which were very enlightening, and allowed myself, and perhaps anyone else who has read this thesis, to understand what dualism, xenophobia, racism, or any other ―us versus them‖ thinking can sound like behind closed doors, even among clinicians themselves who are expected to be the most mindful of how they discuss race and culture.

I‘m not Muslim, I was never raised Muslim, and I have no intentions of converting to

Islam, unlike several of my friends and acquaintances. I could barely get through the Bhagavad

Gita – or the Hindu religious text – because although my Hindi has remained intact, I don‘t remember Sanskrit, and the English translations couldn‘t even capture the richness of the original

Vedic (ancient Indian) writings. I began to feel that even though I was born and raised in the

Middle East, and grew up with Arabic-speaking, Muslim friends, I was still conducting this research from the place of an ‗outsider‘, because my Arabic is elementary, at best, and I‘m an atheist – perhaps agnostic, or ‗spiritual‘, at most. I was initially nervous about this and felt that it would be a major barrier to building rapport with some of my religious participants. Ironically, however, it was the deeply religious and traditional Kuwaiti and other Arab men and women who I connected with the most during the interviews. These interviews were more profound, more powerful, more emotionally intense, more enlightening. They reminded me that religion – despite being exploited for power – has many political, cultural, economic, and psychosocial benefits. Even in their profoundness and emotional rawness, these interviews softened my analysis and made me refrain from ‗blaming culture‘ or ‗blaming religion‘ like I initially did, unwittingly, as I began to feel swayed by some of the ‗anti-American‘ and ‗anti-Arab‘ discourses that permeated several of my interviews. These interviews became the driving force behind a

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more critical analysis because it forced me to ask questions about the factors that shape our ideologies: economic practices, modern discourses that reinforce dualism (i.e., ―us versus them‖ thinking), and how religion can be both the toxin that perpetuates malevolence, as well as the antidote that cures it. This paradox is at the heart of my analysis.

One of my many goals with this project is to emphasize how religion and spirituality can reinforce the richness, vibrancy, warmth, and humanitarian aspects of Kuwaiti culture that are being overshadowed by more modernized, individualistic, neoliberal ideologies and threatening the traditional (and now, modern) sense of coherence in Kuwait. I argue that this is the root of much of the psychological toxicity that care providers – including family members and religious healers – witness among those who utilize their services.

Religion has many faces. While most people discussed how it‘s been exploited, some participants discussed the face of Islam that many do not see. What made that young Kuwaiti man that I mentioned earlier so special is that he never once mentioned the negative faces of religion, or how religion is exploited; in fact, he almost had a naivety about him that was completely unperturbed by the contemporary modern criticisms of religion. In many ways, his narrative became the beacon behind my deeper analysis of religious discourses. He made me realize that Kuwait, despite being highly corrupt, is also a very charitable society, and much of that charity comes from the teachings in Islam: forgiveness, compassion, and humility are among the main ones. This made me think about how people find meaning in their suffering, and took me back to a book by the psychiatrist, Viktor Frankyl, Man’s Search for Meaning, which helped me draw parallels between misery, social defeat, and torture, and how some people find meaning in these difficult but inevitable life experiences that exist in most societies. Those who find

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meaning – often in God, their families, or mere expected human suffering (‗penance‘) – often

‗survive‘, while the nihilists, who have no sense of meaning, often crumble.

I then began to ask myself how people who get raped and beaten consistently, more often than not by the very people who are supposed to protect them, come to find meaning and resilience in their experiences. I couldn‘t think of anything. Do they accept that they deserve it?

Are they indebted to the gods of karma from a previous life, and believe that it is their destiny to suffer in the current one (like I was taught with Hinduism)? I then reflected back on my own experience – not on being raped, I‘m thankful that I‘ve never had to experience that – but on being on the receiving end of what felt like torture at the hands of a very cruel dermatologist and surgeon in India. His name was Dr. Rizvi. Upon several weeks of intense reflexive thought and meditation (as well as some psychotherapy, which I didn‘t find very helpful) I have come to the conclusion that Dr. Rizvi is the reason that I am so drawn towards the study of power in healthcare (and the rest of society), as well as the bioethics surrounding various medical practices. The narration of my experiences will soon explain why I‘m personally driven to challenge authority figures within the caregiving professions who abuse their power, and to align myself (and encourage others to align themselves) with movements of ethics by challenging socio-political structures that promote the hunger for power and its abuse.

I have an auto-immune disease called vitiligo – i.e., my immune system destroys melanocytes (cells that make skin pigment). When I was younger, my face and neck were covered in white patches that often burned and peeled with excessive sun exposure – which was not uncommon since I engaged in a lot of outdoor sports as a child. I hated looking at myself in the mirror, especially as I experienced puberty, and often cried alone in my bathroom. My father, bless his soul, took me to the best doctors he could afford. By the time I was twelve years old, I

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had undergone several alternative and topical treatments (ointments, creams) as well as more mainstream methods to treat vitiligo such as ‗ultraviolet A and B‘ (UVA and UVB) radiation therapies. They involved everything from targeted spot-treatments to the affected areas to me standing in large machines with my eyes closed (to avoid becoming blind) so the laser beams could target my whole body. I still remember feeling like a lab-rat as they examined by whole body under special lights that exposed the vitiligo that was skin deep and not immediately visible to the naked eye. My whole body is covered in it and they may even resurface again one day.

They tend to be triggered and exacerbated by stressful environmental factors. There is still no known ‗cure‘ for vitiligo, and many people can present the phenotype even though no known family member had it. It has now come under the domain of epigenetics since environmental factors are thought to play a critical role in its phenotypic expression. The first time my symptoms presented themselves was after Sadam‘s invasion of Kuwait, while my family and I were living in the neighboring country, Bahrain. My father had stayed back, while my mother, two older brothers and I had been evacuated by the Indian embassy. Bahrain did not get attacked, however it was under constant threat since it was the primary air-base for the U.S. military.

Within a year of returning from India, after the post-war dust had (literally) settled, I began to show symptoms – patches of white around my face, neck, shoulder, and feet, that started to get bigger day by day.

My mother and father tried every treatment that was available in Bahrain, however nothing stopped it from spreading over the years. I had already given up, and I began to accept that this is how I would look forever. The only other option left was what Dr. Rizvi, in New

Delhi, advised: skin graft surgery – often given to burn victims. Dr. Rizvi took out his portfolio that showed the before and after shots of his patients – both male, female, young and old. It was

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hard for my father to resist. A man worried about the dignity and integrity of his daughter – however he defined it culturally – can be an easy sales target. The white patches were more or less gone in the photos! So my father asked about the cost of the surgery – I remember it being very expensive, but he was desperate to fix me, for my own sake. He signed a form and shook the doctor‘s hand.

A few days later, I walked into the surgery room wearing Kappa pants that had buttons all along the side to expose my upper thigh where the doctor would take ―fresh skin‖ samples. I was told that I would be ―put to sleep‖ and ―wouldn‘t feel a thing‖. However, upon arriving to the surgery room, I saw the sharp steel tools, all lined up perfectly on a steel tray, next to the green faux leather doctor‘s bench. I began literally kicking and screaming, making a big scene, begging my mother to tell my father something, begging my father to call off the surgery, pleading with the doctor and his wife, who had no medical training, but would soon be his accomplice in what I feel was medical malpractice, to have some mercy. But I was shushed, silenced, and told that I wouldn‘t feel a thing. Dr. Rizvi looked annoyed at the sight and sound of such a misbehaved, outspoken little girl.

The pills and local anesthesia needles came out. They were not putting me to sleep after all! Did my father know this or was he duped? It didn‘t make a difference anymore. He was the survivor of having dental root canals done as a little boy with no anesthesia whatsoever because his parents could not afford it. In his heart, he felt that it was a necessary evil that would make me ‗tougher‘. General anesthesia is often more expensive and requires a trained anesthesiologist to be present, especially for children. Not having any meant that I was going to be awake to watch them cut me open, until the pills they gave me kicked in (they didn‘t kick in for what felt like an hour). As I was still screaming, Dr Rizvi grabbed a needle and asked his wife to hold my

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head in place, as he injected the skin around my lower eyelid. He told me not to move because if

I did, he could damage something in my eye. At this point, I began to detach from the whole experience. The screams of a twelve year old girl turned into what sounded like the wails of an old woman, crossed with a large bovine animal being tortured. They barely sounded young or human. My brother later told me that he and my father, who were in the waiting room one floor above us, had to vacate the clinic because they couldn‘t bear the sounds of screaming. My mother sat next to me and held my hand.

Eventually, my whole face was numb – it took between five to ten sharp needle pricks to make it numb. And then I watched the skin that they removed from my face being discarded into a steel cup. That was the ―bad skin‖. He then took ―good skin‖ grafts from my thigh and fused it to the open wounds he made to my face. I watched everything. At this point, I was drifting in and out of consciousness, everything became blurry, I was unable to move, my body began feeling more and more paralyzed, my throat was dry from screaming. In retrospect, I don‘t know if this was from the pills or if I was feeling experiencing genuine shock. As I drifted in and out of consciousness, I watched for my mother, felt for her hand – she had left. I looked into Dr Rizvi‘s eyes, my eyes still feeling blood-shot, and he had a look of anger, confusion, perhaps restlessness in them, as if to say, ―why are you awake and being so difficult‖? He gave me more pills. I knew

I just needed to submit – but that moment, when I relaxed my face, and locked eyes with his again while he took more skin grafts from my eye or neck (I can‘t remember which, as I‘m writing this), his brow relaxed too, and his eyes seemed happy, almost as if to say, ―good girl‖.

He was genuinely enjoying this. He was relieved. It was relieving a deep yearning in his soul, which I saw in the moment that we locked eyes. This was my first personal introduction to an

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extreme form of doctor satisfaction at patient compliance. I was being a ―good girl‖, a ―good patient‖, a ―submissive‖, a ―bed lamb‖.

When I woke up again, perhaps two hours later, I felt that the anesthesia may have been wearing off. I could feel pain in my face, neck and thigh. It was sharp, and I could feel the wetness of blood, the cold air of the fan blowing against my open wound. I was exposed. I don‘t know what came over my twelve year old brain, but I felt so instinctual, almost possessed, to execute a plan to grab as many of the sharp surgical objects, already covered in blood, on the tray next to me and cut Dr Rizvi and his wife open, muster up all my strength to run out of the clinic, and run away from home and never look back. I was abandoned. It wasn‘t so much that I felt physically and emotionally tortured by the hands of a physician, it was more that this happened at the consent of people who were supposed to protect me.

Years later, as I was a full-blown teenager in Bahrain, I was okay – I was an average, to high-average student, passionate about the music and literature of the ―hippie generation‖, passionate about challenging the ―status quo‖. I immediately defended myself or anyone else who was talked down to by a teacher or a bully. I yelled at my father and mother if they ever tried to tell me what to do in an authoritarian tone. I became a little bratty and a tomboy – also quite dramatic if I didn‘t get my way – but still kept my head down because I knew it was in my best interests to work my way up to going to university outside of the Middle East. The one itch that I always needed to scratch, however, was related to authority figures. In my 11th grade sculpture class, we were asked to do a sculpture (just the head and bust) of someone who inspired us. I did Freud! But he came out black for some reason. And the top of his head exploded in the kiln before I made another one. Poetic!

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I was initially driven by the harder sciences – I began my studies as a biology student because I wanted to understand vitiligo. I wanted to maybe go into medicine or genetics and try to find a cure. But there was always an itch that wasn‘t getting scratched, questions that never got answered. I took everything from French, to Anthropology, to Economics, Chemistry, and

Biology and it wasn‘t until I took Psychology in my 3rd year and fell in love. Life started making sense again because the more advanced social and critical oriented approaches bridged the gaps between what I was learning in Anthropology, Biology and Economics. I was learning about power, about Machiavellianism, about the ―vulnerable dark triad‖, about inequality, about the psychology of evil – Zimbardo was an interesting man. I even had the pleasure of meeting him at an APA convention in D.C. The experience with Dr. Rizvi that I had locked away so fervently within the recesses of my psyche, began making sense. I started making sense. My ―bad behaviour‖ started making sense. I started to, for the first time, find meaning in my experiences, and I finally understood, personally, and politically, the power of ―resistance‖. I started forgiving my father years ago, who recently just passed away from cancer. I even forgave the evil doctor and his wife. What allowed me to do this was the reflection of my experiences back to the moment that I made as very human connection with Dr. Rizvi when we locked eyes. That was a moment of power being asserted, by him, and accepted, without choice, by me. My older, current self, actually empathizes with him: it was an itch that needed to be scratched. In its rawest sense,

I found common ground with a predator. He is human and all humans have certain drives. When you understand the drive, however inhumane or depraved it appears, you can empathize with it

(without justifying or condoning it), build rapport, and maybe, just maybe, begin to rehabilitate someone. I learned that upon speaking with self-identified sexual predators and narcissists – both in the Middle East and Canada (who I did not interview for this study) – however that topic goes

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beyond the scope of this thesis. Nonetheless, it has heightened my appreciation for the difficulty many clinicians can face while providing care or rehabilitation for those who are oppressed, as well as those who consciously or unconsciously oppress others.

Maybe Nietzsche was right: power is what motives us. Perhaps Frankyl is also right: meaning is what motivates us. Freud would argue pleasure motivates us. Kierkegaard, on the other hand, would argue that the fear of death is what motivates us, and we will do whatever we can to cheat death. The last ten years of academic work has taught me that acceptance of these very human drives – particularly the drive for power, how it is used, what it looks like, how people respond with and without it – can help us move towards a more ―caring‖ society.

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References

―American University of Kuwait psychology students visit the Kuwait Center for Mental Health‖. (2015). Retrieved on July 27, 2016, from http://www.auk.edu.kw/news/showNewsDetails.jsp?id=11108&ndate=1423658110002& newsType=N Abdel-Khalek, A. M. (2004). Does war affect death anxiety level? Seven readings of measurements (1988–2002) before and after the Iraqi invasion of Kuwait. OMEGA- Journal of Death and Dying, 49(4), 287-297. Abushaban, L., Al-Hay, A., Uthaman, B., Salama, A., & Selvan, J. (2004). Impact of the Gulf war on congenital heart diseases in Kuwait. International Journal of Cardiology, 93(2), 157-162. Adib, S. M., Al-Qarmalawi, M. A., Morsy, A. H., & Darif, M. (2001). Socioeconomic variables associated with perinatal mortality in Kuwait. International Journal of Gynecology & Obstetrics, 73(3), 261-263. Afana, A. (2012). Problems in applying diagnostic concepts of PTSD and trauma in the Middle East. The Arab Journal of Psychiatry, 23, 28-34. Ahmed, R. A. (1992). Psychology in the Arab Countries. In Gielen, U. P., Adler, L. L., & Milgram, N. A. (Eds.). Psychology in International Perspective: 50 Years of the International Council of Psychologists (pp. 127-150). Amsterdam: Swets & Zeitlinger. Al Homaizi, D., & Al Homaizi, A. (2014, July 16). Raising Mental Health Awareness in Kuwait. Retrieved from https://www.youtube.com/watch?v=Q2o8iu2cu7Y Al Sager, N. (2014). Acquiring Modernity: Kuwait's Modernity Between Memory and Forgetting. National Council for Culture, Arts and Letters. Al Saleh, K., AlSayed, N., Abd-El-Gawad, W., Mostafa, S., Mostafa, M., & Bedair, A. (2015, May). Palliative performance scale differences between patients referred by specialized cancer center and general hospitals to the palliative care center in Kuwait. In ASCO Annual Meeting Proceedings (Vol. 33, No. 15_suppl, p. e20541). Al-Ansari, E. A., El-Hilu, S., El-Hihi, M. A., & Hassan, K. I. (1990). Patterns of psychiatric consultations in Kuwait general hospitals. General Hospital Psychiatry, 12(4), 257-263. Al-Balhan, E. M. (2006). The Children's Depression Inventory as a reliable measure for post- Iraqi invasion Kuwaiti youth. Social Behavior and Personality: an International Journal, 34(4), 351-366. Albuquerque, J., Deshauer, D., & Grof, P. (2003). Descartes‘ passions of the soul—seeds of psychiatry? Journal of Affective Disorders, 76(1), 285-291. Albuquerque, J., Deshauer, D., & Grof, P. (2003). Descartes‘ passions of the soul—seeds of psychiatry? Journal of Affective Disorders, 76(1), 285-291. Aldea, M. A., & Rice, K. G. (2006). The role of emotional dysregulation in perfectionism and psychological distress. Journal of Counseling Psychology,53(4), 498. Aldrich, D. P. (2011). The externalities of strong social capital: post-tsunami recovery in Southeast India. Journal of Civil Society, 7(1), 81-99.

342

Alegria, M., Mulvaney-Day, N., Torres, M., Polo, A., Cao, Z., & Canino, G. (2007). Prevalence of psychiatric disorders across Latino subgroups in the United States. American Journal of Public Health, 97(1), 68-75. Alhaj, A. (2015). How Literacy Rate, GDP (PPP) and Gender Constrain and Effect Social Contagion in Social Networking (Twitter). Recent Patents on Computer Science, 8(2), 85-89. Al-Hammadi, A. M. (1995). The Destruction of the Healthcare Services in the State of Kuwait during the Period of the Iraqi Aggression. Kuwait City: The Social Development Office. Al-Hammadi, A.M. & Al-Abdalrazaq, A.A. (1994). Atlas of Iraqi War Crimes in the State of Kuwait. Kuwait: Al Qabas Al‐Kandari, F. H., Yacoub, K., & Omu, F. (2001). Initiation factors for substance abuse. Journal of advanced nursing, 34(1), 78-85. Al-Krenawi, A., & Graham, J. R. (2000). Culturally sensitive social work practice with Arab clients in mental health settings. Health & Social Work,25(1), 9-22. Allardyce, J., Gilmour, H., Atkinson, J., Rapson, T., Bishop, J., & McCreadie, R. G. (2005). Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses. The British Journal of Psychiatry, 187(5), 401-406. AlMarri, T. S., & Oei, T. P. (2009). Alcohol and Substance use in the Arabian Gulf region: A review. International Journal of Psychology, 44(3), 222-233. Almazeedi, H., & Alsuwaidan, M. T. (2014). Integrating Kuwait‘s mental health system to end stigma: A call to action. Journal of Mental Health, 23,1–3. Al-Mekaimi, H. (2013). Kuwait Women’s Tepid Political Awakening. World Security Institute. Al-Mughni, H. (1996). Women's organizations in Kuwait. Middle East Report, 32-35. Al-Mughni, H. (2010). The Rise of Islamic Feminism in Kuwait. Review of the Worlds of Muslims and Mediterraneans, 128, 167-182. Retrieved from https://remmm.revues.org/6899

Al-Nakib, F. (2014). Towards an Urban Alternative for Kuwait: Protests and Public Participation. Built Environment 40 (1): 101–117. Al‐Naser, F., Ridha, H. M. A., & Figley, C. R. (2005). Adopting a Strength‐based, Indigenous‐ focused Approach to Studying Kuwait Post‐traumatic Stress. Digest of Middle East Studies, 14(2), 1-10. Alqashan, H. F., & Alzubi, A. (2009). Job satisfaction among counselors working at stress center—Social Development Office—in Kuwait.Traumatology, 15(1), 29. Al-Qimlass, A. (2015). The Counseling Profession in Kuwait: Its Journey and Future. International Journal for the Advancement of Counselling, 37(4), 355-366. Al‐Saffar, N., Deshmukh, A. A., Carter, P., & Adib, S. M. (2005). Effect of information leaflets and counselling on antidepressant adherence: open randomised controlled trial in a psychiatric hospital in Kuwait. International Journal of Pharmacy Practice, 13(2), 123- 131. Al-Sayer, A. (2013). Directory of the Psychological Services in The State of Kuwait. Kuwait City: The Kuwaiti Association for Learning Differences (KALD). Retrieved from http://www.kaldkuwait.com/Files/Others/KALD_Directory_English.pdf

343

Alsuwaidan, M. (n.d.). Mohammad Alsuwaidan, University of Toronto. Retrieved September 2, 2016, from http://utoronto.academia.edu/MohammadAlsuwaidan Al‐Turkait, F. A., & Ohaeri, J. U. (2008). Prevalence and correlates of posttraumatic stress disorder among Kuwaiti military men according to level of involvement in the first Gulf War. Depression and anxiety, 25(11), 932-941. Amatruda, K. (2005). A Visit to Sri Lanka: A humanitarian mission sponsored by the Association for Play Therapy and Operation USA. Retrieved April 1, 2015, from http://www.psychceu.com/tsunami/tsunamijournal.html Amatruda, K. (n.d.) A Field Guide to Disaster Mental Health: The Very Big Wave and the Mean Old Storm. Retrieved April 1, 2015, from http://www.psychceu.com/disasterresponse/field_guide_index.asp Amatruda, K. (n.d.) A Supervisor’s Journal: Clinical Supervision, Law, and Ethics. Retrieved April 2, 2015, from http://www.psychceu.com/super/superindex.asp American Psychiatric Association (APA). (2013). DSM 5. American Psychiatric Association. Anderson, K. M., & Danis, F. S. (2006). Adult daughters of battered women resistance and resilience in the face of danger. Affilia, 21(4), 419-432. Antonovsky, H., & Sagy, S. (1986). The development of a sense of coherence and its impact on responses to stress situations. Journal of Social Psychology, 126(2), 213-226. Applbaum, K. (1998). The sweetness of salvation: consumer marketing and the liberal-bourgeois theory of needs. Current Anthropology, 39(3), 323-350. Applbaum, K. (2004). How to organize a psychiatric congress. Anthropological Quarterly, 77(2), 303-310. Applbaum, K. (2006). Educating for global mental health: the adoption of SSRIs in Japan. In A. Petryna, A. Lakoff, & A. Kleinman (Eds.), Global Pharmaceuticals: Ethics, Markets, Practices (pp. 85-110). Durham & London: Duke University Press. Applbaum, K. (2009). Consumers are patients! Shared decision-making and treatment noncompliance as business opportunity. Transcultural Psychiatry,46(1), 107-130. Arrigo, B., & Fox, D. (2009). Psychology and the law: The crime of policy and the search for justice. In D. Fox, I. Prilleltensky & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (2nd ed) (pp. 159-175). Los Angeles: Sage. Atkinson, R. L. (1996). Hilgard's introduction to psychology. Vol. 12. Philadelphia PA: Harcourt Brace College Publishers. Azaizeh, H., Saad, B., Cooper, E., & Said, O. (2010). Traditional Arabic and Islamic medicine, a re-emerging health aid. Evidence-Based Complementary and Alternative Medicine, 7(4), 419-424. Bajracharya, R., & Sijapati, B. (2012). The Kafala system and its implications for Nepali domestic workers. Center for the Study of Labour Mobility. Retrieved August 7, 2016, from http://www.ceslam.org/docs/publicationManagement/Kafala_Nepali_Domestic_Workers _Female_Migration_Eng.pdf Banchetti-Robino, M. P. (2004). Ibn Sina and Husserl on intention and intentionality. Philosophy East and West, 54(1), 71-82. Bandura, A. (2002). Social cognitive theory in cultural context. Applied Psychology, 51(2), 269- 290. Barrett, D., & Behbehani, J. (2003). Post-traumatic nightmares in Kuwait following the Iraqi invasion. The psychological impact of war trauma on civilians, 135-141.

344

Batstra, L., & Frances, A. (2012). Diagnostic inflation: causes and a suggested cure. The Journal of Nervous and Mental Disease, 200(6), 474-479. Beer, L., & Boswell, T. (2001). The effects of globalization on inequality: a cross-national analysis. Halle Institut Occasional Paper. Beirne, P. (1987). Adolphe Quetelet and the origins of positivist criminology. American Journal of Sociology, 1140-1169. Belliard, J. C., & Ramírez-Johnson, J. (2005). Medical pluralism in the life of a Mexican immigrant woman. Hispanic Journal of Behavioral Sciences,27(3), 267-285. Benjamin Jr, L. T. (2006). Hugo Münsterberg's attack on the application of scientific psychology. Journal of Applied Psychology, 91(2), 414. Bergmann, G. (1956). The contributions of John B. Watson. Psychological Review, 63, 265-276. Bernstein, R. J. (1983). Beyond objectivism and relativism: Science, hermeneutics, and praxis. University of Pennsylvania Press Biggerstaff, D., & Thompson, A. R. (2008). Interpretative phenomenological analysis (IPA): A qualitative methodology of choice in healthcare research. Qualitative Research in Psychology, 5(3), 214-224. Bilal, A. M. (1989). Kuwait drug addiction scene: a changing pattern?.Substance Use & Misuse, 24(12), 1137-1144. Billings, J. S. (1895). Report on the insane, feeble-minded, deaf and dumb, and blind in the United States at the eleventh census, 1890. Govt. Print. Off. Bisson, J. I., Searle, M. M., & Srinivasan, M. (1998). Follow-up study of British military hostages and their families held in Kuwait during the Gulf War. Psychology and Psychotherapy, 71, 247. Blumenthal, A. L. (1998). Leipzig, Wilhelm Wundt, and psychology‘s gilded age. Portraits of Pioneers in Psychology, 3, 31-48. Boring, E. G. (1950). A history of experimental psychology (2nd ed.). New York: Appleton- Century-Crofts. Boswell, T., & Dixon, W. J. (1993). Marx's theory of rebellion: A cross-national analysis of class exploitation, economic development, and violent revolt. American Sociological Review, 681-702. Bourque, F., Van der Ven, E., & Malla, A. (2011). A meta-analysis of the risk for psychotic disorders among first-and second-generation immigrants. Psychological Medicine, 41(05), 897-910. Bourque, F., van der Ven, E., Fusar-Poli, P., & Malla, A. (2012). Immigration, social environment and onset of psychotic disorders. Current Pharmaceutical Design, 18(4), 518-526. Boushey, H. (2008). ―Opting out?‖ The effect of children on women's employment in the United States. Feminist Economics, 14(1), 1-36. Brandt, M. J., & Crawford, J. T. (2016). Answering unresolved questions about the relationship between cognitive ability and prejudice. Social Psychological and Personality Science, DOI: 1948550616660592. Brinkhoff, T. (2015). Kuwait. Retrieved Aug 17, 2016 from http://www.citypopulation.de/Kuwait-Cities.html Brown, T. N. (2003). Critical race theory speaks to the sociology of mental health: Mental health problems produced by racial stratification. Journal of Health and Social Behavior, 292- 301.

345

Brunner, E. (1996). The social and biological basis of cardiovascular disease in office workers. Health and Social Organization: Towards a health policy for the twenty-first century, 272-299. Buckley, M. (2013). Locating neoliberalism in Dubai: migrant workers and class struggle in the autocratic city. Antipode, 45(2), 256-274. Bullock, H. E., & Limbert, W. M. (2009). Class. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 215-231). Los Angeles: Sage Publications. Burns, J. K., Tomita, A., & Kapadia, A. S. (2014). Income inequality and schizophrenia: Increased schizophrenia incidence in countries with high levels of income inequality. International Journal of Social Psychiatry, 60(2), 185-196. Bush, G. (2005, February 9). Continuing Support for Tsunami Relief. Retrieved April 2, 2015, from http://georgewbush-whitehouse.archives.gov/infocus/tsunami/ Buss, D. M. (1995). Evolutionary psychology: A new paradigm for psychological science. Psychological inquiry, 6(1), 1-30. Buss, D. M. (2005). The handbook of evolutionary psychology. John Wiley & Sons. Lipson, J. G., & Meleis, A. I. (1992). The cultural consultant in mental health care: the case of an Arab adolescent. American Journal of Orthopsychiatry, 62(3), 359. Cahill, S. (1997). Wise women: over two thousand years of spiritual writing by women. New York: WW Norton & Company. Calderwood, J. (2010, February 3). Kuwait critics find 12-step cure for addiction goes too far. The National. Retrieved August 19, 2016, from http://www.thenational.ae/news/world/middle-east/kuwaiti-critics-find-12-step-cure-for- addiction-goes-too-far#full Calhoun, C. (1989). Tiananmen, television and the public sphere: internationalization of culture and the Beijing spring of 1989. Public Culture, 2(1), 54-71. Callahan, R. E. (1962). Education and the Cult of Efficiency. Chicago: University of Chicago Press. Carder, P. C., Vuckovic, N., & Green, C. A. (2003). Negotiating medications: patient perceptions of long‐term medication use. Journal of clinical pharmacy and therapeutics, 28(5), 409- 417. Carl, N. (2014). Verbal intelligence is correlated with socially and economically liberal beliefs. Intelligence, 44, 142-148. Carroll, L. (1865/2009). Alice in Wonderland. London: Macmillan Publishers. Castillo, R. J. (1997). Culture & mental illness: A client-centered approach. Thomson Brooks/Cole Publishing Co. Castillo, R. J. (2003). Trance, functional psychosis, and culture. Psychiatry, 66, 9-21. Castillo, R. J. (2006). Schizophrenia, Culture, and Subjectivity: The Edge of Experience and Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia: A Combined Review. American Anthropologist, 28, 229-230. Centers for Disease Control and Prevention. (2011). ―Drug overdose deaths – Florida, 2003- 2009‖. Morbidity and Mortality Weekly Report, 60(26). Retrieved on September 02, 2016, from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a1.htm Chaleby, K. (1985). Brief communication: women of polygamous marriages in an inpatient psychiatric service in Kuwait. The Journal of nervous and mental disease, 173(1), 56-58.

346

Charlson, F., Degenhardt, L., McLaren, J., Hall, W., & Lynskey, M. (2009). A systematic review of research examining benzodiazepine‐related mortality. Pharmacoepidemiology and Drug Safety, 18(2), 93-103. Charmaz, K. (2000). Grounded theory: Objectivist and constructivist methods. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (2nd ed., pp. 509–535). Thousand Oaks: Sage. Cheney, A. M. (2010). " Most Girls Want to be Skinny": Body (Dis)satisfaction among ethnically diverse women. Qualitative Health Research, 1049732310392592. Cherry, F. (2009). Social psychology and social change. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 93-109). Los Angeles: Sage Publications. Ciftci, S. (2010). Modernization, Islam, or social capital: what explains attitudes toward democracy in the Muslim world?. Comparative Political Studies. Clawson, P. (1997). Review of Civil Society in the Middle East. Middle East Quarterly, 2, 353 Clifford, W. K. (1878). On the nature of things-in-themselves. Mind, 9, 57-67. Coates, L., & Wade, A. (2007). Langauge and violence: Analysis of four discursive operations. Journal of Family Violence, 22(7), 511-522. Cohen, A., Patel, V., Thara, R., & Gureje, O. (2008). Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophrenia Bulletin, 34(2), 229-244. Coid, J. W., Kirkbride, J. B., Barker, D., Cowden, F., Stamps, R., Yang, M., & Jones, P. B. (2008). Raised incidence rates of all psychoses among migrant groups: findings from the East London first episode psychosis study. Archives of General Psychiatry, 65(11), 1250- 1258. Conn, D. K., Ferguson, I., Mandelman, K., & Ward, C. (1999). Psychotropic drug utilization in long-term-care facilities for the elderly in Ontario, Canada.International psychogeriatrics, 11(03), 223-233. Cooley, C. H. (1902). The looking-glass self. O’Brien, 126-128. Corcoran, C., Perrin, M., Harlap, S., Deutsch, L., Fennig, S., Manor, O., ... & Susser, E. (2009). Incidence of schizophrenia among second-generation immigrants in the Jerusalem perinatal cohort. Schizophrenia Bulletin, 35(3), 596-602. Corrigan, P. W. (2007). How clinical diagnosis might exacerbate the stigma of mental illness. Social Work, 52(1), 31-39. Cosgrove, L., Krimsky, S., Wheeler, E. E., Kaitz, J., Greenspan, S. B., & DiPentima, N. L. (2014). Tripartite conflicts of interest and high stakes patent extensions in the DSM-5. Costall, A. (1995). Socializing affordances. Theory & Psychology, 5(4), 467-481. Coughlan, R. (2003). General medical and birthing experiences of new mothers in the capital health region: An empirical and socio-historical investigation into the concept of personal agency. Ph.D. dissertation, Department of Psychology, University of Victoria. Coughlan, R. (2006). The social psychology of health care: Consumerism, technology and the ―public good.‖. Health Psychology, 3(1). Coughlan, R. (2006). The Socio-Politics of Technology and Innovation: Problematizing the ‗Caring‘ in Healthcare? Social Theory & Health, 4(4), 334-352. Currin, L., Schmidt, U., Treasure, J., & Jick, H. (2005). Time trends in eating disorder incidence. The British Journal of Psychiatry, 186(2), 132-135. Dain, N. (1989). Critics and dissenters: Reflections on ―anti-psychiatry‖ in the United States. Journal of the History of the Behavioral Sciences, 25(1), 3-25.

347

Danziger, K. (1982). Mid—Nineteenth-Century British Psycho-Physiology: A Neglected Chapter in the History of Psychology. In W.R Woodward & M.G. Ash (Ed.s), The Problematic Psychology (pp. 119-146). New York: Praeger. Danziger, K. (1994). Constructing the subject: Historical origins of psychological research. Cambridge University Press. Danziger, K. (1997). Naming the Mind: How Psychology Found its Language. London, UK: Sage Publications. Davidson, J. R. (2006). After the Tsunami: Mental Health Challenges to the Community for Today and Tommorrow. Physicians Postgraduate Press, 2006. Davis, W. (2009). The Wayfinders: Why Ancient Wisdom Matters in the Modern World. Toronto: House of Anansi. Day, K., Rickett, B., & Woolhouse, M. (2014). Class Dismissed: Putting Social Class on the Critical Psychological Agenda. Social and Personality Psychology Compass, 8(8), 397- 407. De Bel-Air, F. (2013). The demographic and economic framework of migration in Kuwait. Gulf Labour Markets and Migration, 1, 1-11. De Waal, F. (2006). Our inner ape. New York: Penguin Group. De Waal, F. (2009). The age of empathy: nature's lessons for a kinder society. New York: Three Rivers Press De Waal, F. B. (2007). Chimpanzee politics: power and sex among apes. JHU Press. Decker, H. S. (2007). How Kraepelinian was Kraepelin? How Kraepelinian are the neo- Kraepelinians?—from Emil Kraepelin to DSM-III. History of Psychiatry,18 (3), 337-360. Descartes, R. (1641/1842). Meditationes de prima philosophia. Gustav Bethge. Descartes, R. (1989). The Passions of the Soul. Indianapolis: Hackett Publishing Company. Dingfelder, S. F. (2003). Tibetan Buddhism and research psychology: A match made in Nirvana. Monitor on Psychology, 34(11), 46-48. Doherty, M. (1996). The contributions of Hall and Munsterberg to the study of abnormal behavior. Journal of Psychological Inquiry, 1, 1-43. DuBosar, R. (2009). Psychotropic drug prescriptions by medical specialty. American College of Physicians Internist. Retrieved September 4, 2016, from http://acpinternist.acponline.org/archives/2009/11/national-trends.htm?print=true Dumesnil, H., & Verger, P. (2009). Public awareness campaigns about depression and suicide: a review. Psychiatric Services. 60(9), 1203-1213. Dunbar, R. I. (2003). The social brain: mind, language, and society in evolutionary perspective. Annual Review of Anthropology, 163-181. Durrheim, K., Hook, D., & Riggs, D. (2009). Race and racism. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 197-214). Los Angeles: Sage Publications. Dwairy, M., & Achoui, M. (2006). Introduction to three cross-regional research studies on parenting styles, individuation, and mental health in Arab societies. Journal of Cross- Cultural Psychology, 37(3), 221-229. Ebert, R. H., & Ginzberg, E. (1988). The reform of medical education. Health Affairs, 7(2), 5-38. Edis, T., & BouJaoude, S. (2014). Rejecting materialism: Responses to modern science in the Muslim Middle East. In International Handbook of Research in History, Philosophy and Science Teaching (pp. 1663-1690). Netherlands: Springer.

348

Elbadawi, I. A., & Kubursi, A. A. (2014). Kuwaiti democracy: illusive or resilient? American University of Beirut. El-Badri, S., & Mellsop, G. (2011). Clozapine use and outcomes among patients with treatment resistant schizophrenia. Australasian Psychiatry, 19(5), 410-414. El-Hilu, S. M., Mousa, R., Abdulmalek, H., Kamel, N., Zohdi, M., Maher, A., & Al-Aamriti, M. (1990). Psychiatric morbidity among foreign housemaids in Kuwait. International Journal of Social Psychiatry, 36(4), 291-299. El-Katiri, L., Fattouh, B., & Segal, P. (2011). Anatomy of an oil-based welfare state: Rent distribution in Kuwait. Kuwait Programme on Development, Governance, & Globalization in the Gulf States. El-Kebbi, N. M. (2013). Qat Chews, Diwaniyas, and Coffeehouses: Civic Traditions in Yemen, Kuwait, and Egypt (Doctoral dissertation, Emory University). Embassy of India, Kuwait. (n.d.) Bank guarantee for employing an Indian female domestic worker. Retrieved July 19, 2016, from http://www.indembkwt.org/Pages/DomesticWorkerGuarentee.aspx Engels, F. (1969). The condition of the working class in England. Penguin UK. Epstein-Lubow, G., & Andrew Rosenzweig MD, M. P. H. (2010). The use of antipsychotic medication in long term care. Medicine and Health Rhode Island, 93(12), 372. Erickson, C. D., & Al-Timimi, N. R. (2001). Providing mental health services to Arab Americans: Recommendations and considerations. Cultural Diversity and Ethnic Minority Psychology, 7, 308–327. Erikson, E. H. (1968). Identity: youth and crisis. New York: WW Norton & Company. Euromonitor International. (2014). World consumer income and expenditure patterns (14th ed.) London, UK. Evans, S. D., & Loomis, C. (2009). Organizational and community change. In D. Fox, I. Prilleltensky & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (2nd ed) (pp. 373-390). Los Angeles: Sage. Fakhr El-Islam, M. (2008). Arab culture and mental health care. Transcultural Psychiatry, 45(4), 671– 682. Fasano, U., & Iqbal, Z. (2003). GCC countries: From Oil Dependence to Diversification. Washington, D.C.: International Monetary Fund. Fearon, P., Kirkbride, J. B., Morgan, C., Dazzan, P., Morgan, K., Lloyd, T., ... & Mallett, R. (2006). Incidence of schizophrenia and other psychoses in ethnic minority groups: results from the MRC AESOP Study. Psychological Medicine, 36(11), 1541-1550. Fido, A. A., & Husseini, A. M. (1998). Noncompliance with treatment among psychiatric patients in Kuwait. Medical Principles and Practice, 7(1), 28-32. Fido, A. A., & Razik, M. A. (1992). Polypharmacy among psychiatric patients in Kuwait. Medical Principles and Practice, 3(4), 195-198. Fink, R. (1963). Education and the Cult of Efficiency. Studies in Philosophy and Education, 3(1), 52-58. Flynn, R. (2002). Clinical governance and governmentality. Health, Risk & Society, 4(2), 155- 173. Fodor, J. A. (1980). Methodological solipsism considered as a research strategy in cognitive psychology. Behavioral and brain sciences, 3(01), 63-73. Foley, D. K. (1986). Understanding Capital: Marx’s Economic Theory. Harvard University Press.

349

Foucault, M. (1965). Madness and civilization: a history of insanity in the age of reason. London: Tavistock Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: a patient-level meta-analysis. Journal of the American Medical Association, 303(1), 47-53. Fox, A. J., Goldblatt, P. O., & Jones, D. R. (1985). Social class mortality differentials: artefact, selection or life circumstances?. Journal of Epidemiology and Community Health, 39(1), 1-8. Fox, D., Prilleltensky, I., & Austin, S. (2009). Critical Psychology for Social Justice: Concerns and Dilemmas. Fox, D., Prilleltensky, I., & Austin, S. (Eds.). (2009). Critical psychology: an introduction. Sage. Fox, R. W. (1978). So far disordered in mind: Insanity in California, 1870-1930 (Vol. 1). Univ of California Press. Frances, A. (2013). Saving normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life. New York: HarperCollins. Frankyl, V. E. (1959/2006). Man’s search for meaning. Boston: Beacon Press. Freud S (1920/1950). Beyond the Pleasure Principle. New York: Liveright Freud, S. (1923). The Ego and the Id (No. 142). WW Norton & Company. Freud, S. (1930). Civilization and its Discontents. WW Norton & Company. Friedman, M. (1962/2002). Capitalism and Freedom: 40th Anniversary Edition .Chicago: The University of Chicago Press. Gallagher, A. T. (2011). Improving the effectiveness of the international law of human trafficking: A vision for the future of the US Trafficking in Persons reports. Human Rights Review, 12(3), 381-400. Gallagher, S. (2012). Multiple aspects in the sense of agency. New Ideas in Psychology, 30(1), 15-31. Ganesan, M. (2006). Psychosocial response to disasters-some concerns. International review of psychiatry, 18(3), 241-247. Gardner, A. M. (2010). Engulfed: Indian guest workers, Bahraini citizens, and the structural violence of the Kafala system. The University of Puget Sound. Retrieved August 7, 2016, from http://soundideas.pugetsound.edu/cgi/viewcontent.cgi?article=1141&context=faculty_pu bs George, S. (1999, March). A short history of neoliberalism. In conference on Economic Sovereignty in a Globalising World (Vol. 24, p. 26) Gergen, K. J. (2001). Psychological science in a postmodern context. American Psychologist, 56 (10), 803. Gergen, K. J. (2001). Psychological science in a postmodern context.American psychologist, 56(10), 803. Ghabra, S. (1997). Kuwait and the dynamics of socio-economic change. The Middle East Journal, 358-372. Ghabra, S. (2014). Kuwait at the crossroads of change or political stagnation. Middle East Institute-Policy Papers series, 2, 1-24. Gibson, J. J. (1977). The theory of affordances. Hilldale, USA.

350

Giustiniani, V. R. (1985). Homo, humanus, and the meanings of 'humanism'. Journal of the History of Ideas, 167-195. Godin, B. (2007). From eugenics to scientometrics: Galton, Cattell, and men of science. Social Studies of Science, 37(5), 691-728. Goffman, E. (1968). Asylums: Essays on the social situation of mental patients and other inmates. Garden City: Transaction Publishers. Gökmenoğlu, T., Eret, E., & Kiraz, E. (2010). Crises, reforms, and scientific improvements: Behaviorism in the last two centuries. Elementary Education Online, 9(1), 292-300. Gold, J., & Gold, I. (2014). Suspicious Minds: How Culture Shapes Madness. New York: Simon and Schuster, Inc., Free Press. Gómez‐de‐Regil, L., Kwapil, T. R., & Barrantes‐Vidal, N. (2014). Predictors of expressed emotion, burden and quality of life in relatives of Mexican patients with psychosis. Journal of psychiatric and mental health nursing, 21(2), 170-179. Gould, S. J. (1991). Exaptation: A crucial tool for an evolutionary psychology. Journal of Social Issues, 47(3), 43-65. Gravetter, F. J., & Forzano, L. B. (2012). Research Methods for the Behavioral Sciences. Wadsworth, Cengage Learning. Greenberg, G. (2013). The Book of Woe: The DSM and the Unmaking of Psychiatry. New York: The Penguin Group. Greenwood, C. (1992). New World Order or Old? The Invasion of Kuwait and the Rule of Law. The Modern Law Review, 55(2), 153-178. Grob, G. N. (1991). Origins of DSM-I: a study in appearance and reality. American Journal of Psychiatry, 148(4), 421-431. Grob, G. N. (2011). The attack of psychiatric legitimacy in the 1960s: Rhetoric and reality. Journal of the History of the Behavioral Sciences, 47(4), 398-416. Gunter, B., Dickinson, R. (2013). News Media in the Arab World: A Study of 10 Arab and Muslim Countries. New York: Bloomsbury Publishing USA. Hackforth, R. (1952). Plato: Phaedrus (No. 119). Cambridge University Press Haraway, D. J. (1988). Situated knowledges: the science question in feminism and the privelage of partial perspective. Feminist Studies, 14(3), 575-597. Haraway, D. J. (1988). Situated knowledges: The science question in feminism and the privilege of partial perspective, Feminist Studies, 14(3), 575-597. Harris, B. (2009). What critical psychologists should know about the history of psychology. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction (pp. 20-35). Los Angeles: Sage Publications. Harrist, R. S., & Richardson, F. C. (2014). Pathologizing the normal, individualism, and virtue Ethics. Journal of Contemporary Psychotherapy, 44(3), 201-211. Hartelius, G., Caplan, M., & Rardin, M. A. (2007). Transpersonal psychology: Defining the past, divining the future. The Humanistic Psychologist, 35(2), 135-160. Hartmann, A. S., Thomas, J. J., Wilson, A. C., & Wilhelm, S. (2013). Insight impairment in body image disorders: Delusionality and overvalued ideas in anorexia nervosa versus body dysmorphic disorder. Psychiatry research,210(3), 1129-1135. Hassan, O. (2012). Constructing America's freedom agenda for the Middle East: democracy or domination. New York: Routledge.

351

Hassan, R. (2002). Is Islam a Help or Hindrance to Women‘s Development? In J. Meuleman (Ed.) Islam in the Era of Globalization: Muslim Attitudes towards Modernity and Identity (pp. 136-151). New York: Taylor & Francis. Healy, D. (1997). The Antidepressant Era. Boston: Harvard University Press. Healy, D. (2003). Let them eat Prozac. Toronto: James Lorimer & Company. Healy, D. (2006). The new medical Oikumene. In A. Petryna, A. Lakoff, & A. Kleinman (Eds.), Global Pharmaceuticals: Ethics, Markets, Practices (pp. 61-84). Durham & London: Duke University Press. Heidegger, M. (1962). Being and time [Sein und Zeit]. Macquire, J. & Robinson, E.(trans.). Oxford: Basil Blackwell. Herb, M. (2005). No representation without taxation? Rents, development, and democracy. Comparative Politics, 297-316. Hergenhahn, B., & Henley, T. (2013). An introduction to the history of psychology. Cengage Learning. Hesse-Biber, S. N., & Leavy, P. (2011). The Practice of Qualitative Research (2nd ed.). Thousand Oaks: Sage. Heywood, L., & Drake, J. (2004). ‗It‘s All About the Benjamins‘: Economic Determinants of Third Wave Feminism in the United States. In Third wave feminism (pp. 13-23). Palgrave Macmillan UK. Hodges, B., Inch, C., & Silver, I. (2001). Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950-2000: a review. American Journal of Psychiatry, 158(10), 1579-1586. Hodgetts, D., & Chamberlain, K. (2000). The social negotiation of people‘s views on the causes of illness. Journal of Health Psychology, 5(3), 325-336. Hodson, G., & Busseri, M. A. (2012). Bright minds and dark attitudes lower cognitive ability predicts greater prejudice through right-wing ideology and low intergroup contact. Psychological Science, 23(2), 187-195. Hollifield, M., Hewage, C., Gunawardena, C. N., Kodituwakku, P., Bopagoda, K., & Weerarathnege, K. (2008). Symptoms and coping in Sri Lanka 20–21 months after the 2004 tsunami. The British Journal of Psychiatry, 192(1), 39-44. Holt, M. (1994). Dewey and the" cult of efficiency": Competing ideologies in collaborative pedagogies of the 1920s. Journal of Advanced Composition, 73-92. Hooley, J. M. (1998). Expressed emotion and locus of control. The Journal of nervous and mental disease, 186(6), 374-378. Hopper, K. (2007). Rethinking social recovery in schizophrenia: what a capabilities approach might offer. Social Science & Medicine, 65(5), 868-879. Horden, P. (2005). The earliest hospitals in Byzantium, Western Europe, and Islam. Journal of Interdisciplinary History, 35(3), 361-389 Horkheimer, M., & Adorno, T. W. (1944). 1972. Dialectic of enlightenment.London: Allen Lane. Hornik, R., Jacobsohn, L., Orwin, R., Piesse, A., & Kalton, G. (2008). Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health, 98(12), 2229-2236. Horvitz-Lennon, M., Kilbourne, A. M., & Pincus, H. A. (2006). From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs, 25(3), 659-669. Hothersall, D. (1984). History of psychology. Philadelphia: Temple University Press.

352

Howes, O. D., & Kapur, S. (2009). The dopamine hypothesis of schizophrenia: version III—the final common pathway. Schizophrenia bulletin, 35(3), 549-562. http://www.kuwaitconstitution.org/kuwaitconstitutionenglish.html Hudson, M. C. (1991). After the Gulf war: prospects for democratization in the Arab world. Middle East Journal, 45(3), 407-426. Huhn, M., Tardy, M., Spineli, L. M., Kissling, W., Förstl, H., Pitschel-Walz, G., ... & Leucht, S. (2014). Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: a systematic overview of meta-analyses. JAMA Psychiatry, 71(6), 706-715. Hunsley, J., Elliott, K., & Therrien, Z. (2014). The efficacy and effectiveness of psychological treatments for mood, anxiety, and related disorders. Canadian Psychology/Psychologie Canadienne, 55(3), 161. Huxley, A. (1932). Brave New World. London: Harper Perennial Modern Classics Huygens, I. (2009). From colonization to globalization: continuities in colonial ‗commonsense‘. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 267-284). Los Angeles: Sage Publications ICH (n.d.) The International Conference for Harmonization: Harmonization for Better Health. Retrieved on May 12, 2015, from http://www.ich.org/about/history.html Illegal Teachers run from Beladiya in Kuwait. (2015, May 10). Retrieved from http://www.lifeinkuwaitblog.com/2015/05/illegal-teachers-run-from-beladiya- in.html IMS Institute for Health Informatics. The use of medicines in the United States: Review of 2011. (April, 2012). Retrieved July, 27, 2016, from https://www.imshealth.com/files/web/IMSH%20Institute/Reports/The%20Use%20of%20 Medicines%20in%20the%20United%20States%202011/IHII_Medicines_in_U.S_Report _2011.pdf IMShealth (2015) How Social Media Intelligence is Strengthening Pharma Strategy. IMShealth. (2015). ―Company History‖ [website cite] Inglehart, R. (1971). The silent revolution in Europe: intergenerational change in post-industrial societies. American Political Science Review, 65(04), 991-1017. Inglehart, R. (1988). The renaissance of political culture. American Political Science Review, 82(04), 1203-1230. Inglehart, R. (1997). Modernization and Postmodernization: Cultural, Economic, and Political Change in 43 Societies. Princeton, NJ: Princeton University Press. Inglehart, R. (2000). Globalization and postmodern values. Washington Quarterly, 23(1), 215-2 Inglehart, R. (2006). Mapping global values. Comparative Sociology, 5(2), 115-136. Inglehart, R. F. (2008). Changing values among western publics from 1970 to 2006. West European Politics, 31(1-2), 130-146. Inglehart, R., & Welzel, C. (2010). Changing mass priorities: The link between modernization and democracy. Perspectives on Politics, 8(02), 551-567. Inglehart, R., Moaddel, M., & Tessler, M. (2006). Xenophobia and in-group solidarity in Iraq: A natural experiment on the impact of insecurity.Perspectives on Politics, 4(03), 495-505. Insel, T. R. (2009). Translating scientific opportunity into public health impact: a strategic plan for research on mental illness. Archives of General Psychiatry, 66(2), 128-133. International Conference on Harmonization (ICH). (n.d.). Gulf Central Committee for Drug Registration. Retrieved from http://www.ich.org/about/organisation-of- ich/coopgroup/gcc.html

353

Islam, G., & Zyphur, M. J. (2008). Concepts and directions in critical industrial/organizational psychology. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction Critical psychology (pp. 110-125). Los Angeles: Sage Publications. Ismael, J. S., & Ismael, S. T. (2013). Children of the occupation: a decade after the invasion. International Journal of Contemporary Iraqi Studies, 7(2), 131-146. James, W. (1890). The consciousness of self. The principles of psychology, 8. James, W. (1907). Pragmatism: A New Name for Some Old Ways of Thinking. Ed. Frederick H. Burkhardt, Fredson Bowers, and Ignas K. Skrupskelis. Cambridge, MA: Harvard UP. James, W. (1909a). The Meaning of Truth: A Sequel to Pragmatism. 1909. Reprint. Ed. Frederick Burkhardt et al. The Works of William James, 2. James, W. (1909b). A pluralistic universe. Harvard University Press. Johnson, T., & Aly Sergie, M. (2014). Islam: governing under Sharia. Retrieved on July19, 2016, from http://www.cfr.org/religion/islam-governing-under-sharia/p8034 Jorm, A. F. (2000). Mental health literacy Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177(5), 396-401. Jorm, A. F. (2012). Mental health literacy: empowering the community to take action for better mental health. American Psychologist, 67(3), 231. Juster, R. P., Seeman, T., McEwen, B. S., Picard, M., Mahar, I., Mechawar, N., ... & Lanoix, D. (2016). Social inequalities and the road to allostatic load: From vulnerability to resilience. Developmental Psychopathology. Kaladchibachi, S., & Al-Dhafiri, A. M. (2016). Mental health care in Kuwait: toward a community-based decentralized approach. International Social Work, 1-6. Kant, I., & Woods, A. W. (Ed.). (1781/2001). Critique of pure reason. In Basic Writings of Kant (pp. 1-116). New York: Random House. Karmi, G. (2005). Women, Islam and patriarchalism. In H. Moghissi (Ed.) Women and Islam: Critical Concepts in Sociology. New York: Routledge. Karno, M., Jenkins, J. H., De la Selva, A., Santana, F., Telles, C., Lopez, S., & Mintz, J. (1987). Expressed emotion and schizophrenic outcome among Mexican-American families. The Journal of nervous and mental disease, 175(3), 143-151. Katzman, K. (2015). Kuwait: Governance, Security, and U.S. Policy. Congressional Research Service. Retrieved from http://www.fas.org/sgp/crs/mideast/RS21513.pdf Katzman, M. A., & Lee, S. (1997). Beyond body image: The integration of feminist and transcultural theories in the understanding of self-starvation. International Journal of Eating Disorders, 22(4), 385-394. Kendler, K. S. (1988). Kraepelin and the diagnostic concept of paranoia. Comprehensive Psychiatry, 29(1), 4-11. Kendler, K. S., & Schaffner, K. F. (2011). The dopamine hypothesis of schizophrenia: an historical and philosophical analysis. Philosophy, Psychiatry, & Psychology, 18(1), 41- 63. Kennedy, B. P., Kawachi, I., & Prothrow-Stith, D. (1996). Income distribution and mortality: cross sectional ecological study of the Robin Hood index in the United States. British Medical Journal, 312(7037), 1004-1007. Kety, S. S., Wender, P. H., Jacobsen, B., Ingraham, L. J., Janson, L., Faber, B., & Kinney, D. K. (1994). Mental illness in the biological and adoptive relatives of schizophrenic adoptees: replication of the Copenhagen study in the rest of Denmark. Archives of general psychiatry, 51(6), 442-455.

354

Khadduri, M., & Ghareeb, E. (1997). War in the Gulf, 1990-91: The Iraq-Kuwait Conflict and its Implications. New York: Oxford University Press. Khan, A., & Harroff-Tavel, H. (2011). Reforming the Kafala: Challenges and opportunities in moving forward. Asian and Pacific Migration Journal, 20(3-4), 293-313. Khordagui, H., & Al-Ajmi, D. (1993). Environmental impact of the Gulf War: an integrated preliminary assessment. Environmental Management, 17(4), 557-562. Khullar, N., Deeny, M., Scull, N. C., & Hamdan, E. (2016b). Body Builders’ Perceptions and Patterns of Performance Enhancing Drug Use in Kuwait: A Qualitative Study. Manuscript in preparation. Khullar, N., Scull, N. C., Deeny, M. C., & Hamdan, E. (2016a). Prevalence and predictors of anabolic-androgenic steroid use among gym users in Kuwait: a preliminary study. International Journal of Men’s Health,15(2) 144-156. Kinninmont, J. (15 February 2013). "The Case of Kuwait: Debating Free Speech and Social Media in the Gulf". Retrieved from http://islamicommentary.org/2013/02/jane- kinninmont-the-case-of-kuwait-debating-free-speech-and-social-media-in-the-gulf/ Kirkbride, J. B., Barker, D., Cowden, F., Stamps, R., Yang, M., Jones, P. B., & Coid, J. W. (2008). Psychoses, ethnicity and socio-economic status. The British Journal of Psychiatry, 193(1), 18-24. Kirkbride, J. B., Jackson, D., Perez, J., Fowler, D., Winton, F., Coid, J. W., ... & Jones, P. B. (2013). A population-level prediction tool for the incidence of first-episode psychosis: translational epidemiology based on cross-sectional data. British Medical Journal Open, 3(2), e001998. Kirmayer, L. J. (2002). Psychopharmacology in a globalizing world: the use of antidepressants in Japan. Transcultural Psychiatry, 39(3), 295-322. Kirmayer, L. J. (2006). Beyond the ‗new cross-cultural psychiatry‘: cultural biology, discursive psychology and the ironies of globalization. Transcultural Psychiatry, 43(1), 126-144. Kirsch, I. (2009). Antidepressants and the placebo response. Epidemiologia e Psichiatria Sociale, 18(04), 318-322. Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention & Treatment, 1(2), 2a. Kitanaka, J. (2006). Society in Distress: The Psychiatric Production of Depression in Contemporary Japan. Ph.D. dissertation, Department of Anthropology, McGill University Kitzinger, C. (1997). Lesbian and gay psychology: a critical analysis. In D. Fox and I. Prilleltensky (Eds.), Critical Psychology: An Introduction (pp. 202-216). London: Sage. Klaum, A. G. (1980). Kuwait: Prosperity from a Sea of Oil. The Link, 13(4), 1-16. Klein, N. (2007). The shock doctrine: The rise of disaster capitalism. New York: Henry Holt & Company. Kleinman, A. van der Geest, S. (2009). ‗Care‘ in health care: remaking the moral world of medicine. Medische Anthopologie, 21, 158-168. Kleinman, A. (1997). Triumph or pyrrhic victory? The inclusion of culture in DSM-IV. Harvard review of psychiatry, 4(6), 343-344. Kleinman, A. (2006). What really matters: Living a moral life amidst uncertainty and danger. Oxford: Oxford University Press. Kleinman, A. (2008). Commentary on Alex Cohen et al: ―Questioning an axiom: better prognosis for schizophrenia in the developing world‖. Schizophrenia bulletin, 34(2), 249-250

355

Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of internal medicine, 88(2), 251-258. Kleinman, A., Kleinman, J., & Lee, S. (1999). Introduction to the transformation of social experience in Chinese society: Anthropological, psychiatric and social medicine perspectives. Culture, Medicine and Psychiatry, 23(1), 1-6. Kleisiaris, C. F., Sfakianakis, C., & Papathanasiou, I. V. (2014). Health care practices in ancient Greece: The Hippocratic ideal. Journal of Medical Ethics and History of Medicine, 7(6), 1-5. Kluijver, R. (March 2013). Cultural developments in Kuwait. Retrieved from http://gulfartguide.com/g/wp-content/uploads/2013/11/Contemporary-Art-in-the-Gulf- for-print.pdf Knapp, M., Mangalore, R., & Simon, J. (2004). The global costs of schizophrenia. Schizophrenia Bulletin, 30(2), 279. Kotler, P., & Zaltman, G. (1971). Social marketing: an approach to planned social change. The Journal of Marketing, 3-12. Kraepelin, E., & Diefendorf, A. R. (1915). Clinical psychiatry: a text-book for students and physicians. Macmillan. Kristensen, P., Weisæth, L., & Heir, T. (2009). Psychiatric disorders among disaster bereaved: an interview study of individuals directly or not directly exposed to the 2004 tsunami. Depression and anxiety, 26(12), 1127-1133. Kumar, S., Murhekar, M. V., Hutin, Y., Subramanian, T., Ramachandran, V., & Gupte, M. D. (2007). Prevalence of posttraumatic stress disorder in a coastal fishing village in Tamil Nadu, India, after the December 2004 Tsunami. American Journal of Public Health, 97(1), 99-101. Kuwait Center for Mental Health (2010). Kuwait Psychological Medicine Hospital. Retrieved from http://psychiatrykuwait.com/index Kuwait Center for Mental Health. (2013). In Facebook [Hospital page]. Retrieved from https://www.facebook.com/pages/Kuwait-Centre-for-Mental- Health/145389948914582?fref=ts Kuwait Ministry of Public Health. (1993). Annual Statistical Abstract. Ministry of Health. Retrieved from http://www.csb.gov.kw/Socan_Statistic_EN.aspx?ID=18 Kuwait Ministry of Public Health. (2013). Annual Statistical Abstract. Ministry of Health. Retrieved from http://www.csb.gov.kw/Socan_Statistic_EN.aspx?ID=18 Kuwait Pharmacy (2012). Drug Information Database. Retrieved from http://www.kuwaitpharmacy.com/DrugInfo.aspx Labrie, Y. (2014). What Role Do the Public and Private Sectors Play in Pharmaceutical Innovation?. Health Care. Laing, R. D. (1967). The Politics of Experience. London: Penguin Books. Lake, C. R. (2008). Hypothesis: grandiosity and guilt cause paranoia; paranoid schizophrenia is a psychotic mood disorder; a review. Schizophrenia bulletin, 34(6), 1151-1162. Lakoff, G. (2006). Whose freedom? The battle over America's most important idea. New York: Farrar, Straus and Giroux. Le Grange, D., Louw, J., Breen, A., & Katzman, M. A. (2004). The meaning of ‗self-starvation‘in impoverished black adolescents in South Africa. Culture, medicine and psychiatry, 28(4), 439-461. Leary, D. E. (Ed.). (1994). Metaphors in the history of psychology. Cambridge University Press.

356

Lee, H. (2003). Outcomes-based education and the cult of educational efficiency: Using curriculum and assessment reforms to drive educational policy and practice. Education research and perspectives, 30, 60-107. Lee, S. (1995). Self-starvation in context: Towards a culturally sensitive understanding of anorexia nervosa. Social Science & Medicine, 41(1), 25-36. Lee, S. (1996). Reconsidering the status of anorexia nervosa as a Western culture-bound syndrome. Social Science & Medicine, 42(1), 21-34. Lee, S., Lee, A. M., Ngai, E., Lee, D. T., & Wing, Y. K. (2001). Rationales for food refusal in Chinese patients with anorexia nervosa. International Journal of Eating Disorders, 29(2), 224-229. Lee, S., Ng, K. L., Kwok, K., & Fung, C. (2010). The changing profile of eating disorders at a tertiary psychiatric clinic in Hong Kong (1987–2007).International Journal of Eating Disorders, 43(4), 307-314. Llabre, M. M., & Hadi, F. (2009). War-related exposure and psychological distress as predictors of health and sleep: a longitudinal study of Kuwaiti children. Psychosomatic medicine, 71(7), 776-783. Lombardi, C. B. (2013). Constitutional Provisions Making Sharia 'A' or 'The' Chief Source of Legislation: Where Did They Come from? What Do They Mean? Do They Matter? American University International Law Review, 28(3), 733-74. Lopes, R., Soares, R., Coelho, R., & Figueiredo-Braga, M. (2015). Angiogenesis in the pathophysiology of schizophrenia—A comprehensive review and a conceptual hypothesis. Life sciences, 128, 79-93. Lovie, A. D. (1983). Attention and behaviourism—fact and fiction. British Journal of Psychology, 74(3), 301-310. Lykes, M. B., & Coquillon, E. D. (2009). Psychosocial Trauma, Poverty, and Human Rights in Communities Emerging from War. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 285-299). Los Angeles: Sage Publications. MacAskill, W. (2013). The infectiousness of nihilism. Ethics, 123(3), 508-520. MacDonald, V. (2016, September 27). Rally held in Cobourg for migrants‘ rights. Northumberland Today. Retrieved from http://www.northumberlandtoday.com/2016/09/27/rally-held-in-cobourg--for-migrants- rights Marecek, J. & Hare-Mustin, R. T. (2009). Clinical Psychology: The Politics of Madness. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 75-90). Los Angeles: Sage Publications. Mark. (2015, June 2). Teachers Working Illegally in Kuwait. Message posted to http://248am.com/mark/gossip/teachers-working-illegally-in-kuwait/ Markota, M., Sin, J., Pantazopoulos, H., Jonilionis, R., & Berretta, S. (2014). Reduced Dopamine Transporter Expression in the Amygdala of Subjects Diagnosed With Schizophrenia. Schizophrenia bulletin, 40(5), 984-991. Marková, I. (2012). ‗Americanization‘ of European Social Psychology. History of the Human Sciences, 25(3), 108-116. Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365(9464), 1099- 1104.

357

Marmot, M. G., Stansfeld, S., Patel, C., North, F., Head, J., White, I., ... & Smith, G. D. (1991). Health inequalities among British civil servants: the Whitehall II study. The Lancet, 337(8754), 1387-1393. Marx, K. (1906). Capital: A critique of political economy, volume 1. Chicago: Kerr Marx, K., & Engels, F. (1965). The German Ideology (1845). London. Maslow, A. H. (1943). "A theory of human motivation". Psychological Review, 50, 370-396. McCubbin, M. (2009). Oppression and Empowerment: The Genesis of a Critical Analysis of Mental Health. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 300-316). Los Angeles: Sage Publications McGrath, J., El-Saadi, O., Cardy, S., Chapple, B., Chant, D., & Mowry, B. (2001). Urban birth and migrant status as risk factors for psychosis: an Australian case-control study. Social Psychiatry and Psychiatric Epidemiology, 36(11), 533-536. McGruder, J. (2002). Life experience is not a disease or why medicalizing madness is counterproductive to recovery. Occupational Therapy in Mental Health, 17(3-4), 59-80 McGruder, J. (2004). Disease models of mental illness and aftercare patient education: Critical observations from meta-analyses, cross-cultural practice and anthropological study. The British Journal of Occupational Therapy, 67(7), 310-318. McKenzie, D., Theoharides, C., & Yang, D. (2014). Distortions in the international migrant labor market: Evidence from Filipino migration and wage responses to destination country economic shocks. American Economic Journal: Applied Economics, 6(2), 49-75. McKenzie, K., Fearon, P., & Hutchinson, G. (2008). Migration, ethnicity and psychosis. Society and psychosis, 143-160. Mead, G. H. (1925). The genesis of the self and social control. International journal of Ethics, 251-277. Mead, G. H., & Mind, H. (1934). Self and society. Chicago: University of Chicago. Meuleman, J. (2002). Islam in the Era of Globalization: Muslim Attitudes towards Modernity and Identity. New York: Taylor & Francis. Mill, J. S. (1859/1989). On liberty. Cambridge University Press. Miller, A. C. (2006). Jundi-Shapur, bimaristans, and the rise of academic medical centres. Journal of the Royal Society of Medicine, 99(12), 615-617. Miller, A. R., Lalonde, C. E., McGrail, K. M., & Armstrong, R. W. (2001). Prescription of methylphenidate to children and youth, 1990–1996. Canadian Medical Association Journal, 165(11), 1489-1494. Miller, V. M., Gouvion, C. M., Davidson, B. L., & Paulson, H. L. (2004). Targeting Alzheimer‘s disease genes with RNA interference: an efficient strategy for silencing mutant alleles. Nucleic Acids Research, 32(2), 661-668. Ministry of Foreign Affairs, Japan. (1997). Joint Statement on the U.S.-Japan enhanced initiative on deregulation and competition policy under the U.S.-Japan Framework for a new economic partnership. Retrieved on May 6, 2015, from http://www.mofa.go.jp/policy/economy/summit/1997/joint.html Moftah, L. (2015, January 5). Kuwait Lawmaker under fire for Alcohol Legalization Remarks: MP proposes overturning Drinking Ban at Concerts. Retrieved from http://www.ibtimes.com/kuwait-lawmaker-under-fire-alcohol-legalization- remarks-mp- proposes-overturning-1773252 Morris, D. J. (2015). The Evil Hours: A Biography of Post-Traumatic Stress Disorder. New York: Houghton Mifflin Harcourt Publishing.

358

Munro, A. (1999). Delusional disorder: paranoia and related illnesses. Cambridge University Press. Münsterberg, H. (1898a). The danger from experimental psychology. Atlantic Monthly, 81, 159-167. Münsterberg, H. (1898b). The teacher and the laboratory: A reply. Atlantic Monthly, 81, 824– 829. Münsterberg, H. (1903). The St. Louis Congress of Arts and Science: A letter to the editor. Science, 18, 788. Münsterberg, H. (1908). On the witness stand. New York: Clark, Boardman. Munsterberg, H. (1914). Psychology and industrial efficiency. Bloomsbury Publishing. Murray, K. E., Davidson, G. R., & Schweitzer, R. D. (2010). Review of refugee mental health interventions following resettlement: best practices and recommendations. American Journal of Orthopsychiatry, 80(4), 576-585. Nader, K. O., Pynoos, R. S., Fairbanks, L. A., Al-Ajeel, M., Al-Asfour, A. (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32, 407-416. Nader, K., & Fairbanks, L. (1994). The suppression of re-experiencing: Impulse control and somatic symptoms in children following traumatic exposure. Anxiety, Stress, & Coping,7, 229-239 Nader, K., & Pynoos, R.S. (1993). The children of Kuwait following the Gulf crisis. In Lewis, L. & Fox, N. (Eds.). Effect of war and violence on children (pp. 181-195). Hillsdale, NJ: Lawrence Erlbaum Publishers Nagel, C. & Ayoob, A. (2015). Community activism: advocacy, identity politics, and the formation of a collective consciousness. In M. Amer & G. Awad (Eds)., Handbook of Arab American Psychology (pp. 76-___). New York: Routledge. National Center for Crisis Management (NCCM). (2013). Katie Amatruda. Retrieved April 1, 2015, from http://www.nc-cm.org/biokateamatruda.htm National Institutes of Health. Diseases of the Mind: Highlights of American Psychiatry through 1900. (October 2, 2014). Retrieved March 9, 2015, from http://www.nlm.nih.gov/hmd/diseases/ Neuner, F., Catani, C., Ruf, M., Schauer, E., Schauer, M., & Elbert, T. (2008). Narrative exposure therapy for the treatment of traumatized children and adolescents (KidNET): from neurocognitive theory to field intervention. Child and adolescent psychiatric clinics of North America, 17(3), 641-664. Ngai, E. S., Lee, S., & Lee, A. M. (2000). The variability of phenomenology in anorexia nervosa. Acta Psychiatrica Scandinavica, 102(4), 314-317. Nolen-Hoeksema, S., & Rector, N. A. (2004). Abnormal psychology. Boston: McGraw-Hill. Norcross, J. C., & Wampold, B. E. (2011). What works for whom: Tailoring psychotherapy to the person. Journal of Clinical Psychology, 67(2), 127-132. Nord, W. (1977). A Marxist critique of humanistic psychology. Journal of Humanistic Psychology, 17, 75-83. Oishi, N. (2005). Women in motion: Globalization, state policies, and labor migration in Asia. Stanford University Press. Okasha, A. (1999)ue. Mental health in the Middle East: an Egyptian perspective. Clinical Psychology Review, 19(8), 917-933.

359

Orange, D. M. (2001). From Cartesian minds to experiential worlds in psychoanalysis. Psychoanalytic Psychology, 18(2), 287. Orange, D. M. (2001). From Cartesian minds to experiential worlds in psychoanalysis. Psychoanalytic Psychology, 18(2), 287. Organization of the Petroleum Exporting Countries (OPEC). (2016). Kuwait. Retrieved July 26, 2016, from http://www.opec.org/opec_web/en/about_us/165.htm Orwell, G. (1949). Nineteen eighty-four. London: Penguin. Orwell, G. (1949). Nineteen eighty-four. London: Penguin. Oskay, C. (2010). Tribalism, State Formation and Citizenship in Kuwait (Doctoral dissertation, Middle East Technical University). Oyserman, D., & Lee, S. W. (2008). Does culture influence what and how we think? Effects of priming individualism and collectivism. Psychological bulletin,134(2), 311. Oyserman, D., Coon, H. M., & Kemmelmeier, M. (2002). Rethinking individualism and collectivism: evaluation of theoretical assumptions and meta-analyses. Psychological bulletin, 128(1), 3. Palmer, R. R. (2014). The age of the Democratic Revolution: a political history of Europe and America, 1760-1800. Princeton University Press. Palmieri, P. A., Peterson, L. T., & Ford, E. W. (2007). Technological iatrogenesis: New risks force heightened management awareness. Journal of Healthcare Risk Management, 27(4), 19-24. Parker, I. (2005). Qualitative psychology: introducing radical research. Berkshire: McGraw Hill Educationma. Parker, I., & Spears, R. (1996). Psychology and society: Radical theory and practice. London: Pluto Press. Petryna, A. (2006). Globalizing human subjects research. In A. Petryna, A. Lakoff, & A. Kleinman (Eds.), Global Pharmaceuticals: Ethics, Markets, Practices (pp. 33-60). Durham & London: Duke University Press. Petryna, A. (2011). The competitive logic of global clinical trials. Social Research: An International Quarterly, 78(3), 949-974. Pettitt, P. B. (2002). The Neanderthal dead: exploring mortuary variability in Middle Palaeolithic Eurasia. Before Farming, 1(4), 1-19. Pfeifer, K. (2002). Kuwait‘s Economic Quandary. Middle East Research and Information Project, 223, 10-13. Pharoah, P. D., & Melzer, D. (1995). Variation in prescribing of hypnotics, anxiolytics and antidepressants between 61 general practices. British Journal of General Practice, 45(400), 595-599. Pickett, K. E., & Wilkinson, R. G. (2010). Inequality: an underacknowledged source of mental illness and distress. The British Journal of Psychiatry,197(6), 426-428. Pickett, K. E., & Wilkinson, R. G. (2015). Income inequality and health: a causal review. Social Science & Medicine, 128, 316-326. Pickett, K. E., & Wilkinson, R. G. (2015). Income inequality and health: a causal review. Social Science & Medicine, 128, 316-326. Pippin, R. B. (1991). Idealism and agency in Kant and Hegel. Journal of Philosophy, 88, 532. Porter, B. (2014). The Lion's Share: A History of British Imperialism 1850-2011. Routledge. Post, J. M. (2009). Reframing of martyrdom and jihad and the socialization of suicide terrorists. Political Psychology, 30(3), 381-385.

360

Potter, J., & Edwards, D. (1999). Social representations and discursive psychology: From cognition to action. Culture & Psychology, 5(4), 447-458. Pourmand, D., Kavanagh, D. J., & Vaughan, K. (2005). Expressed emotion as predictor of relapse in patients with comorbid psychoses and substance use disorder. Australian and New Zealand Journal of Psychiatry, 39(6), 473-478. Prilleltensky, I., Prilleltensky, O., & Voorhees, C. (2009). Psychopolitical validity in counselling and therapy. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 355-372). Los Angeles: Sage Publications. Radley, A., & Billig, M. (1996). Accounts of health and illness: Dilemmas and representations. Sociology of Health & Illness, 18(2), 220-240. Rajkumar, A. P., Premkumar, T. S., & Tharyan, P. (2008). Coping with the Asian tsunami: Perspectives from Tamil Nadu, India on the determinants of resilience in the face of adversity. Social Science & Medicine, 67(5), 844-853. Ranasinghe, P. D., & Levy, B. R. (2007). Prevalence of and sex disparities in posttraumatic stress disorder in an internally displaced Sri Lankan population 6 months after the 2004 Tsunami. Disaster Medicine and Public Health Preparedness, 1(01), 34-41. Reicher, S. (1996). The reactionary practice of radical psychology: revoking the Faustian contract. In I. Parker & R. Spears (Eds.)., Psychology and Society: Radical Theory and Practice (pp. 230-240). London: Pluto Press. Richards, A., & Waterbury, J. (1998). A Political Economy of the Middle East. Boulder: Westview Press. Richards, D. A. (1974). Free speech and obscenity law: Toward a moral theory of the First Amendment. University of Pennsylvania Law Review, 45-91. Riva, M. A., & Cesana, G. (2013). The charity and the care: the origin and the evolution of hospitals. European journal of internal medicine, 24(1), 1-4. Rives, J. B. (2006). Religion in the Roman empire. Wiley-Blackwell. Rizzo, H. M. (2005). Islam, democracy, and the status of women: The case of Kuwait. New York: Routedge. Robbins, B. D. (2008). What is the good life? Positive psychology and the renaissance of humanistic psychology. The Humanistic Psychologist, 36(2), 96-112. Rogers C. R. & Skinner, B. F. (1956). Some issues concerning the control of human behavior. Science, 124, 1057-1066. Ross, S., Cleland, J., & Macleod, M. J. (2006). Stress, debt and undergraduate medical student performance. Medical Education, 40(6), 584-589. Rothman, D. (1981). Social Control: the uses and abuses of the concept in the history of incarceration. Rice University Studies, 67, 9-20. Ruf, M., Schauer, M., Neuner, F., Catani, C., Schauer, E., & Elbert, T. (2010). Narrative exposure therapy for 7‐to 16‐year‐olds: A randomized controlled trial with traumatized refugee children. Journal of traumatic stress, 23(4), 437-445. Russon, J. (2003). Human experience: Philosophy, neurosis, and the elements of everyday life. SUNY Press. Sager, A., Koch, C., Tawfiq, I. (2008). Gulf Yearbook 2006-2007. Dubai, UAE: I. B. Tauris. Said, E. W. (1979). Orientalism. New York, NY: Vintage Books. Salem, O. (December, 2010). Depression Patients aren’t getting Medication. The National, UAE. Retrieved from http://www.thenational.ae/news/uae-news/health/depression- patients-arent-getting-medication

361

Saliba, G. (1995). A history of Arabic astronomy: planetary theories during the golden age of Islam (No. 19). New York: NYU Press. Salsman, N. L., & Linehan, M. M. (2012). An investigation of the relationships among negative affect, difficulties in emotion regulation, and features of borderline personality disorder. Journal of Psychopathology and Behavioral Assessment, 34(2), 260-267. Sam, D. L., & Berry, J. W. (2010). Acculturation when individuals and groups of different cultural backgrounds meet. Perspectives on Psychological Science, 5(4), 472-481. Sapolsky, R. M. (1993). Endocrinology alfresco: psychoendocrine studies of wild baboons. Recent Progress in Hormone Research, 48, 437. Sapolsky, R. M. (2005). The influence of social hierarchy on primate health. Science, 308(5722), 648-652. Saul, J. R. (2009). The Collapse of Globalism: And the Reinvention of the World. Toronto: Penguin Canada. Schoon, I., Cheng, H., Gale, C. R., Batty, G. D., & Deary, I. J. (2010). Social status, cognitive ability, and educational attainment as predictors of liberal social attitudes and political trust. Intelligence, 38(1), 144-150. Schultz, D. P. (1969). A history of modern psychology. New York: Academic Press. Schutte, N. S., & Malouff, J. M. (2011). Emotional intelligence mediates the relationship between mindfulness and subjective well-being. Personality and Individual Differences, 50(7), 1116-1119. Schutte, N. S., & Malouff, J. M. (2011). Emotional intelligence mediates the relationship between mindfulness and subjective well-being. Personality and Individual Differences, 50(7), 1116-1119. Schwartz, S. J., Côté, J. E., & Arnett, J. J. (2005). Identity and agency in emerging adulthood two developmental routes in the individualization process. Youth & Society, 37(2), 201- 229. Scull, A. T. (1989). Social order/mental disorder: Anglo-American psychiatry in historical perspective (Vol. 3). University of California Press. Scull, N. C. (2011). Forgiveness, revenge, and adherence to Islam as moderators for psychological well-being and depression among survivors of the 1990 Iraqi invasion of Kuwait. The American University of Kuwait. Scull, N. C., Khullar, N., Al-Awadhi, N., & Erheim, R. (2014). A qualitative study of the perceptions of mental health care in Kuwait. International Perspectives in Psychology: Research, Practice, Consultation, 3(4), 284 Sears, K., Godfrey, C. M., Luctkar-Flude, M., Ginsburg, L., Tregunno, D., & Ross-White, A. (2014). Measuring competence in healthcare learners and healthcare professionals by comparing self‐assessment with objective structured clinical examinations: a systematic review. JBI Database of Systematic Reviews and Implementation Reports, 12(11), 221- 272. Sedlacek, T. (2011). Economics of good and evil: The quest for economic meaning from Gilgamesh to Wall Street. Oxford University Press.S Seeman, M. V. (2011). Canada: psychosis in the immigrant Caribbean population. International Journal of Social Psychiatry, 57(5), 462-470. Selten, J. P., & Cantor-Graae, E. (2005). Social defeat: risk factor for schizophrenia?. The British Journal of Psychiatry, 187(2), 101-102.

362

Shah, N. M. (2004). Women's socioeconomic characteristics and marital patterns in a rapidly developing Muslim society, Kuwait. Journal of Comparative Family Studies, 163-183. Shah, N. M. (2007). Migration and Refugee Movements in the Middle East and North Africa. The American University of Cairo, Egypt. Shah, N. M. (2007, October). Migration to Kuwait: trends, patterns and policies. In Conference on Migration and Refugee Movements in the Middle East and North Africa. The American University in Cairo, Egypt. Shah, N. M., Shah, M. A., Chowdhury, R. I., & Menon, I. (2002). Foreign domestic workers in Kuwait: Who employs how many. Asian and Pacific Migration Journal, 11(2), 247-269. Sharav, V. H. (2006). ―NIH Conflict of Interest Rules "Option of Corruption": children victimized‖, Alliance for Human Research Protection. Retrieved, September 3, 2016, from http://ahrp.org/nih-conflict-of-interest-rules-option-of-corruption-children- victimized/ Sherman, H. (1976). Dialectics as a Method. Critical Sociology, 6(4), 57-64. Shirokanova, А. (2012). The postmaterialist shift and individualization in the Black Sea–Baltic Region. Belarus State University. Shorter, E. (1986). Paralysis: the rise and fall of a ―hysterical‖ symptom. Journal of Social History, 19(4), 549-582. Shorter, E. (1987). The first great increase in anorexia nervosa. Journal of Social History, 21, 69- 96. Shorter, E. (1990). ‗Private Clinics in Central Europe‘1850–1933. Social History of Medicine, 3(2), 159-195. Shorter, E. (1997). Multiple chemical sensitivity: pseudodisease in historical perspective. Scandinavian journal of work, environment & health, 35-42. Shorter, E. (1998). A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. In Cahan, Douglas Hospital, 248-55. Shultziner, D., & Tétreault, M. A. (2011). Paradoxes of democratic progress in Kuwait: the case of the Kuwaiti women's rights movement. Muslim World Journal of Human Rights, 7(2). Silverstein, B. (2014). Gender differences in the prevalence of somatic versus pure depression: a replication. The American Journal of Psychiatry, 159(6), 1051-1052. Silverstein, S. M., & Keane, B. P. (2011). Perceptual organization impairment in schizophrenia and associated brain mechanisms: review of research from 2005 to 2010. Schizophrenia Bulletin, 37(4), 690-699. Singer, M., & Baer, H. (2012). Introducing medical anthropology: a discipline in action. Lanham: Rowman Altamira. Singh-Manoux, A., Adler, N. E., & Marmot, M. G. (2003). Subjective social status: its determinants and its association with measures of ill-health in the Whitehall II study. Social Science & Medicine, 56(6), 1321-1333. Sloan, T. (2009). Doing Theory. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 319-334). Los Angeles: Sage Publications. Smith, J. A., & Osborn, M. (2008). Interpretative Phenomenological Analysis. In J. A. Smith (Ed.), Qualitative Psychology: A Practical Guide to Methods (pp. 53-80). London: Sage. Smith, J. A., Harré, R. & Van Langenhove, L. (1995). Idiography and the case study. In J. A. Smith, R. Harre & L. Van Langenhove (Eds.) Rethinking Psychology. London: Sage.

363

Smith, J. A., Harré, R. & Van Langenhove, L. (1995). Idiography and the case study. In J. A. Smith, R. Harre & L. Van Langenhove (Eds.) Rethinking Psychology. London: Sage. Smith, R. (1982). Wilhelm Wundt Resurrected. The British Journal for the History of Science, 15(03), 285-293. Sokal, M. M. (1980). Science and James McKeen Cattell, 1894 to 1945. Science, 209(4452), 43- 52. Solecki, R. S. (1975). Shanidar IV, a Neanderthal flower burial in northern Iraq. Science, 190, 880-881. Spitzer, R. L. (2012). Spitzer reassesses his 2003 study of reparative therapy of homosexuality. Archives of Sexual Behavior, 41(4), 757-757. Starks, H., & Trinidad, S. B. (2007). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17(10), 1372- 1380. Staub, M. E. (2011). Madness is civilization: When the diagnosis was social, 1948-1980. University of Chicago Press. Stein, D. (2000). Views of mental illness in Morocco: Western medicine meets the traditional symbolic. Canadian Medical Association Journal, 163(11), 1468-1470. Steinitz, V., & Mishler, E. G. (2009). Critical psychology and the politics of resistance. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction to Critical Psychology (pp. 391-409). Los Angeles: Sage Publications. Stephenson, L. (2011). Women and the Malleability of the Kuwaiti Dīwāniyya.Journal of Arabian Studies, 1(2), 183-199. Stephenson, P. H., Wolfe, N. K., Coughlan, R., & Koehn, S. D. (2000). A methodological discourse on gender, independence, and frailty: Applied dimensions of identity construction in old age. Journal of Aging Studies, 13(4), 391-401. Stompe, T., Karakula, H., Rudaleviciene, P., Okribelashvili, N., Chaudhry, H. R., Idemudia, E. E., & Gscheider, S. (2006). The pathoplastic effect of culture on psychotic symptoms in schizophrenia. World Cultural Psychiatry Research Review, 1(3/4), 157-163. Stone, G. R. (2003). Judge Learned Hand and the Espionage Act of 1917: A Mystery Unraveled. The University of Chicago Law Review, 335-358. Strauss, A., & Corbin, J. (1998). Basics of Qualitative Research (2nd ed.). Thousand Oaks: Sage. Suleiman, M. (2010). The Autobiography I Wrote Begins at a Zaghawa Village in Darfur. Buckhinghamshire: AuthorHouse. Summerfield, D. (2006). Survivors of the tsunami: dealing with disaster. Psychiatry, 5(7), 255- 256. Summerfield, D. (2008). How scientifically valid is the knowledge base of global mental health?. BMJ: British Medical Journal, 336(7651), 992. Sutterland, A. L., Dieleman, J., Storosum, J. G., Voordouw, B. A., Kroon, J., Veldhuis, J., ... & Sturkenboom, M. C. (2013). Annual incidence rate of schizophrenia and schizophrenia spectrum disorders in a longitudinal population-based cohort study. Social psychiatry and psychiatric epidemiology, 48(9), 1357-1365. Swader, C. S., & Kosals, L. (2013). Post-socialist anomie through the lens of economic modernization and the formalization of social control. Higher School of Economics Research Paper No. WP BPR, 17. Swartz, L. (1987). Illness negotiation: the case of eating disorders. Social Science & Medicine, 24(7), 613-618.

364

Szasz, T. (1974). The myth of mental illness: foundations of a theory of personal conduct, revised edition. Perennial, New York. Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15(2), 113. Szasz, T. S. (1961). The uses of naming and the origin of the myth of mental illness. American Psychologist, 16(2), 59. Tamimi, A. D. (2013, September 22). Kuwait reliance on migrant workers distorts labour market. Almonintor: The Pulse of the Middle East. Retrieved July 12, 2016, from http://www.al-monitor.com/pulse/business/2013/09/kuwait-labor-market-reliance- foreign-workers.html Tavris, C. (1993). The mismeasure of woman. Feminism & Psychology, 3(2), 149-168. Taylor, E., & Wozniak, R. H. (1996). Pure Experience: The Response to William James. Bristol: Thoemmes Press Teo, T. (2009). Philosophical Concerns in Critical Psychology. In D. Fox, I. Prilleltensky, & S. Austin (Eds.), Critical Psychology: An Introduction (pp. 36-53). Los Angeles: Sage Publications Tetreault, M. A., & al-Mughni, H. (1995). Gender, Citizenship, and Nationalism in Kuwait. British Journal of Middle Eastern Studies, 22 (1/2), 64-80. The CIA World Factbook. (2016). Kuwait. Retrieved on July 19, 2016, from https://www.cia.gov/library/publications/the-world-factbook/geos/ku.html The Constitution of The State of Kuwait. (2014). Retrieved from http://www.kuwaitconstitution.org/kuwaitconstitutionenglish.html The Kuwait Times (2014, November 20). ‘Mentally ill’ Ethiopian maids come to Kuwait – Psychiatrist demands more attention. Retrieved November 3, 2015, from http://news.kuwaittimes.net/mentally-ill-ethiopian-maids-come-kuwait-psychiatrist- demands-attention/ The World Economic Forum (WEF). (2015). The Global Gender Gap Report 2015. Retrieved July 24, 2016, from http://www3.weforum.org/docs/GGGR2015/cover.pdf Thompson, C. J., & Hirschman, E. C. (1995). Understanding the socialized body: a poststructuralist analysis of consumers' self-conceptions, body images, and self-care practices. Journal of Consumer Research, 139-153. Thorndike, E. L. (1898/1911). Animal intelligence: An experimental study of the associative processes in animals. Psychological Monographs, 2. Timetric. (2015). Kuwait national disposable income. Retrieved July 12, 2016, from https://timetric.com/index/AJKqzy3DTBOK0pEF22uNFA/ Titchener, E. B. (1921). Wilhelm Wundt. The American Journal of Psychology, 161-178. Tolman, C. (1994). Psychology, Society and Subjectivity: An Introduction to German Critical Psychology. Routledge. Tolman, C. W. (2009). Holzkamp's Critical Psychology as a Science from the Standpoint of the Human Subject. Theory & Psychology, 19(2), 149-160. Tronto, J. C. (1993). Moral Boundaries: A Political Argument for an Ethic of Care. London: Routledge Tuke, S. (1813). Description of The Retreat. York: W. Alexander. Ulman, J. D. (1996). Radical Behaviourism, selectionism, and social action. In I. Parker & R. Spears (Eds.), Psychology and Society: Radical Theory and Practice (pp. 81-90). London: Pluto Press.

365

United Nations Children‘s Fund (UNICEF). (2011). Kuwait: MENA Gender Equality Profile – Status of Girls and Women in the Middle East and North Africa. Retrieved from http://www.unicef.org/gender/files/Kuwait-Gender-Eqaulity-Profile-2011.pdf United States Department of State. (2013). Kuwait 2013 Human Rights Report. Bureau of Democracy, Human Rights & Labour. Retrieved from http://www.state.gov/documents/organization/220573.pdf Unützer, J., Schoenbaum, M., Druss, B. G., & Katon, W. J. (2006). Transforming mental health care at the interface with general medicine: report for the presidents commission. Psychiatric Services, 57(1), 37-47. van der Ven, E., Bourque, F., Joober, R., Selten, J. P., & Malla, A. K. (2012). Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec. The Canadian Journal of Psychiatry, 57(5), 300- 308. van Os, J., Pedersen, C. B., & Mortensen, P. B. (2004). Confirmation of synergy between urbanicity and familial liability in the causation of psychosis. American Journal of Psychiatry, 161(12), 2312-2314. Vaughan, K., Doyle, M., McConaghy, N., Blaszczynski, A., Fox, A., & Tarrier, N. (1992). The relationship between relative's Expressed Emotion and schizophrenic relapse: an Australian replication. Social Psychiatry and Psychiatric Epidemiology, 27(1), 10-15. Veling, W., Selten, J. P., Mackenbach, J. P., & Hoek, H. W. (2007). Symptoms at first contact for psychotic disorder: comparison between native Dutch and ethnic minorities. Schizophrenia Research, 95(1), 30-38. Vickery, K. (2010). Widening the psychiatric gaze: Reflections on PsychoDoctor, depression, and recent transitions in Japanese mental health care. Transcultural Psychiatry, 47(3), 363-391. von Peter, S. (2008). The experience of ‗Mental Trauma' and its transcultural application. Transcultural psychiatry, 45(4), 639-651. Vygotsky, L. S. (1980). Mind in society: The development of higher psychological processes. Harvard university press. Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression. Contemporary Family Therapy, 19(1), 23-39. Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression. Contemporary Family Therapy, 19(1), 23-39. Walker, L. E. (1987). Inadequacies of the masochistic personality disorder diagnosis for women. Journal of Personality Disorders, 1(2), 183-189. Wampold, B. E., & Brown, G. S. J. (2005). Estimating variability in outcomes attributable to therapists: a naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73(5), 914. Wang, P., Lin, M., Pedrosa, E., Hrabovsky, A., Zhang, Z., Guo, W., ... & Zheng, D. (2015). CRISPR/Cas9-mediated heterozygous knockout of the autism gene CHD8 and characterization of its transcriptional networks in neurodevelopment. Molecular Autism, 6(1), 1-18. Watenpaugh, K. D. (2014). Being Modern in the Middle East: Revolution, Nationalism, Colonialism, and the Arab Middle Class. Princeton University Press. Watson, J. B. (1919). Psychology as the Behaviourist Views it. Philadelphia: J. B. Lippincott Company

366

Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Simon and Schuster. Wedge, M. (2016). A disease called childhood: Why ADHD became an American epidemic. New York: Penguin Random House, LLC. Weiten, W. (2007). Psychology: Themes and variations. Boston: Cengage Learning. Welzel, C., & Inglehart, R. (2005). Liberalism, postmaterialism, and the growth of freedom. International Review of Sociology, 15(1), 81-108. Wentz, D. L. (2005). Finding a cause on the road to Gaul. Mental Health Weekly, 15(7), 5-6. Wertheimer, M. (2012). A brief history of psychology. London: Taylor & Francis. Whitley, R. (2012, October). The antipsychiatry movement: dead, diminishing, or developing? In Open Forum of the American Psychiatric Association (Vol. 63, No. 10). WHO (2002). Nations for Mental Health: Final Report. Mental Health Policy and Service Development, Department of Mental Health and Substance Dependence. WHO. (2013a). Mental Health Action Plan. World Health Organization. WHO. (2013b). List of Most Essential Medications. World Health Organization. WHO. (2014). Country Cooperation Strategy for WHO and Kuwait 2012–2016. WHO. (2015). Noncommunicable diseases. (2015, January 1). Retrieved March 16th , 2015, from http://www.who.int/mediacentre/factsheets/fs355/en/ Widiger, T. A., & Spitzer, R. L. (1991). Sex bias in the diagnosis of personality disorders: Conceptual and methodological issues. Clinical Psychology Review, 11(1), 1-22. Wilkinson, R. G. (1997). Socioeconomic determinants of health. Health inequalities: relative or absolute material standards? British Medical Journal, 314(7080), 591. Wilkinson, R. G. (2002). Unhealthy societies: the afflictions of inequality. Routledge. Wilkinson, R. G. (2011, October 24). How economic inequality harms societies. Retrieved from https://www.ted.com/talks/richard_wilkinson?language=en Wilkinson, R. G. (2011, October 24). How economic inequality harms societies. Retrieved on June 7, 2016, from https://www.ted.com/talks/richard_wilkinson?language=en Wilkinson, R. G., & Pickett, K. E. (2009). Income inequality and social dysfunction. Annual Review of Sociology, 493-511. Willig, C. (2008). Introducing Qualitative Research in Psychology. London: Open University Press. Wills, E. R. (2013). Democratic Paradoxes: Women‘s Rights and Democratization in Kuwait. The Middle East Journal, 67(2), 173-184 World Health Organization (WHO), World Organization of National Colleges, Academies, & Academic Associations of General Practitioners/Family Physicians. (2008). Integrating mental health into primary care: a global perspective. World Health Organization. Wright, R. J., Fay, M. E., Suglia, S. F., Clark, C. J., Evans, J. S., Dockery, D. W., & Behbehani, J. (2010). War-related stressors are associated with asthma risk among older Kuwaitis following the 1990 Iraqi invasion and occupation. Journal of Epidemiology and Community Health, 64(7), 630-635. Young, A. (1995). Reasons and causes for post-traumatic stress disorder. Transcultural Psychiatry, 32(3), 287-298. Young, A. (2008). A time to change our minds: Anthropology and psychiatry in the 21st century. Culture, Medicine, and Psychiatry, 32(2), 298-300.

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Zolkowska, K., Cantor-Graae, E., & McNeil, T. F. (2001). Increased rates of psychosis among immigrants to Sweden: is migration a risk factor for psychosis? Psychological Medicine, 31(04), 669-678.

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Appendix A Information and Consent Form: Mental Health Professionals

Principal Investigator: Principal Supervisor: Neha Khullar Dr. Rory Coughlan Department of Psychology Department of Psychology Trent University Trent University

Ph: +965-6065-7004 (Kuwait) Ph: +1 (705) 748-1011 ext 1079 Ph: +1 (705) 772-9855 (Canada) e-mail: [email protected] e-mail: [email protected] Appendices

The goal of this research is to understand your experiences as a mental health professional in Kuwait. It is hoped that your participation will help us understand the general themes related to the experiences of being a mental health professional, as well as your perceptions about the current mental health policies and general clinical practices in Kuwait. Neither the researcher nor the research supervisor has any commercial interest in this or any other project. The interview will last approximately 60-90 minutes. The interview will be open-ended, which allows you to discuss subjects within the broad parameters of this study that YOU feel are important and that you would like to discuss. This interview will be tape-recorded and your interviewer may take brief notes to augment the analytical process. The interview will be transcribed (typed up word-for-word) and all the data will be kept for 5 years. The interview recording as well as the transcription records will be encrypted (password-protected) using the TrueCrypt encryption software so that only the researcher will have access to it. Before deciding to participate in this study you should know that: Your comments and discussion will be treated in the strictest confidence. You anonymity will be preserved and any reference to other professionals in the Kuwaiti community, friends, family members or other individuals you mention will be coded and pseudonyms will be used in the transcripts. Your participation is voluntary, you have the right to not answer any question, and you may withdraw from the study at any time with no negative consequences to you whatsoever. Nobody at this or any other institution will be given information as to your choice to participate or not. Should you choose to withdraw part-way through the interview all notes and tape-recordings will be destroyed and none of the data will be used in the study. If you wish to withdraw from the study after the interview, you may contact the researchers at the information provided above. All of the information given by you during the course of the interview will be kept in the strictest confidentiality. All the tapes and transcripts of your remarks and opinions will be kept in a secured place and access to them will not be granted to any other person not working directly on

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this project. No other person at this university nor any other institution will have access to this data. All the information you give will remain anonymous. Any tape-recorded information or transcripts of your remarks will be coded and you will not be identified in any way. No part of your taped interview will be played in public, used as a teaching aid in university classes nor played at any scholarly meeting. Only the researcher and a research assistant (for the sole purpose of transcribing the interview) at Trent University will hear or play the tapes and there will be no reference to your name or any other identifying remarks (other than the coded number) made on the recording. The data will be used solely towards understanding your experiences and opinions. The findings may be presented at scholarly meetings and any discussion of this research will be made without any reference to you, any institution (e.g. hospital or university) you are affiliated with, anyone you may have mentioned or any other identifying information. We may also use this research as a contribution to a scholarly article and we would like your permission to use occasional quotes that do not identify you in any way. This project has received approval from the Trent University Research Ethics Committee. If you have any queries that cannot be answered by the researchers, please feel free to contact Trent University Office of Research at 705-748-1011 ext. 7050 or email Karen Mauro at [email protected]. Having read this letter of consent and having had an opportunity to receive answers to any of my questions regarding this research project, I willingly agree to participate in this open-ended interview that will investigate my experiences as a mental health professional in Kuwait. I agree to have this interview tape-recorded and I have received a copy of this consent form.

______Participant Signature Date

I have fully explained the participant‟s rights and answered all questions.

______Interviewer Signature Date

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Appendix B Information and Consent Form: Clients and Patients

Principal Investigator: Principal Supervisor: Neha Khullar Dr. Rory Coughlan Department of Psychology Department of Psychology Trent University Trent University

Ph: + 1 (705) 761 8605 (Canada) Ph: + 1 (705) 748-1011 ext 1079 Ph: +965-6065-7004 (Kuwait) e-mail: [email protected] e-mail: [email protected]

The goal of this research is to understand your experiences utilizing mental health services in Kuwait. We hope that your participation will help us understand the general themes related to your perceptions about, and evaluations of, the mental health sector. We would also like to understand your opinions of any policies (that you‘re aware of) and general mental health practices in Kuwait. Neither the researcher nor the research supervisor has any commercial interest in this or any other project. The interview will last approximately 60-90 minutes. The interview will be open-ended, which allows you to discuss subjects within the broad parameters of this study that YOU feel are important and that you would like to discuss. This interview will be tape-recorded and your interviewer may take brief notes to augment the analytical process. The interview will be transcribed (typed up word-for-word) and all the data will be kept in a secure place for 5 years, after which it will be destroyed permanently. The interview recording as well as the transcription records will be encrypted (password-protected) using the TrueCrypt encryption software so that only the researcher will have access to it. Before deciding to participate in this study you should know that: Your comments and discussion will be treated in the strictest confidence. You anonymity will be preserved and any reference to mental health professionals in the Kuwaiti community, friends, family members or other individuals you mention will be coded and pseudonyms will be used in the transcripts. Your participation is voluntary, you have the right to remain completely anonymous, you have the right to not answer any question, and you may withdraw from the study at any time with no negative consequences to you whatsoever. Nobody at this or any other institution will be given information as to your choice to participate or not. Should you choose to withdraw part-way through the interview all notes and tape-recordings will be destroyed and none of the data will be used in the study. If you wish to withdraw from the study after the interview, you may contact the researchers at the information provided above, and all your information pertaining to the study will be permanently destroyed. All of the information given by you during the course of the interview will be kept in the strictest confidentiality. All the tapes and transcripts of your remarks and opinions will be kept in a secured

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place and access to them will not be granted to any other person not working directly on this project. No other person at this university nor any other institution will have access to this data. All the information you give will remain anonymous. Any tape-recorded information or transcripts of your remarks will be coded and you will not be identified in any way. No part of your taped interview will be played in public, used as a teaching aid in university classes nor played at any scholarly meeting. Only the researcher and a research assistant (for the sole purpose of transcribing the interview) at Trent University will hear or play the tapes and there will be no reference to your name or any other identifying remarks (other than the coded number) made on the audio recording. The data will be used solely towards understanding your experiences and opinions. The research findings may be presented at scholarly meetings and any discussion of this research will be made without any reference to you, any institution (e.g. clinic, health center or university) you are affiliated with, anyone you may have mentioned, or any other identifying information. We may also use this research as a contribution to a scholarly article and we would like your permission to use occasional quotes that do not identify you in any way. Although the interview will be conducted with the highest of ethical standards, talking about some experiences may be emotionally distressing to some individuals, however this psychological risk is very minimal. In the event that you feel you want to stop the interview, it will immediately be stopped, and none of your data will be used for the study. In the event that you feel you require some emergency psychological assistance, you may call a private emergency distress line and speak to a mental health professional at 9729-9068. This project has received approval from the Trent University Research Ethics Committee. If you have any queries that cannot be answered by the researchers, please feel free to contact Trent University Office of Research at 705-748-1011 ext. 7050 or email Karen Mauro at [email protected].

Having read this letter of consent and having had an opportunity to receive answers to any of my questions regarding this research project, I willingly agree to participate in this open- ended interview that will investigate my experiences with seeking mental health services in Kuwait. I agree to have this interview tape-recorded and I have received a copy of this consent form. ______Participant Signature Date

I have fully explained the participant‟s rights and answered all questions.

______Interviewer Signature Date

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Appendix C Information and Consent Form: Kuwait Community Members

Principal Investigator: Principal Supervisor: Neha Khullar Dr. Rory Coughlan Department of Psychology Department of Psychology Trent University Trent University Ph: +965-6065-7004 Ph: (705) 748-1011 ext 1079 e-mail: [email protected] e-mail: [email protected]

The goal of this research is to understand your perceptions about mental health and illness as a member of the Kuwaiti community. It is hoped that your participation will help us understand the general themes related to the experiences of being a member of the Kuwaiti community as well as your perceptions about the current mental health policies (any that you‘re aware of) and general clinical practices in Kuwait. Neither the researcher nor the research supervisor has any commercial interest in this or any other project. The interview will last approximately 60-90 minutes. The interview will be open-ended, which allows you to discuss subjects within the broad parameters of this study that YOU feel are important and that you would like to discuss. This interview will be tape-recorded and your interviewer may take brief notes to augment the analytical process. The interview will be transcribed (typed up word-for-word) and all the data will be kept for 5 years. The interview recording as well as the transcription records will be encrypted (password-protected) using the TrueCrypt encryption software so that only the researcher will have access to it. Before deciding to participate in this study you should know that: Your comments and discussion will be treated in the strictest confidence. You anonymity will be preserved and any reference to anyone in the Kuwaiti community, including friends, family, or other individuals you mention will be coded and pseudonyms will be used in the transcripts. Your participation is voluntary, you have the right to not answer any question, and you may withdraw from the study at any time with no negative consequences to you whatsoever. Nobody at this or any other institution will be given information as to your choice to participate or not. Should you choose to withdraw part-way through the interview all notes and tape-recordings will be destroyed and none of the data will be used in the study. If you wish to withdraw from the study after the interview, you may contact the researchers at the information provided above, and they will permanently destroy your information for the study and not use it in the final report. All of the information given by you during the course of the interview will be kept in the strictest confidentiality. All the tapes and transcripts of your remarks and opinions will be kept in a secured place and access to them will not be granted to any other person not working directly on this project. No other person at this university nor any other institution will have access to this data. 373

All the information you give will remain anonymous. Any tape-recorded information or transcripts of your remarks will be coded and you will not be identified in any way. No part of your taped interview will be played in public, used as a teaching aid in university classes nor played at any scholarly meeting. Only the researcher and a research assistant (for the sole purpose of transcribing the interview) at Trent University will hear or play the tapes and there will be no reference to your name or any other identifying remarks (other than the coded number) made on the recording. The data will be used solely towards understanding your experiences and opinions. The findings may be presented at scholarly meetings and any discussion of this research will be made without any reference to you, any institute you mention (e.g. your workplace, hospitals, universities), or any other identifying information. We may also use this research as a contribution to a scholarly article and we would like your permission to use occasional quotes that do not identify you in any way. This project has received approval from the Trent University Research Ethics Board (REB). If you have any queries that cannot be answered by the researchers, please feel free to contact the Trent University Office of Research at 705-748-1011 ext. 7050 or email Karen Mauro at [email protected].

Having read this letter of consent and having had an opportunity to receive answers to any of my questions regarding this research project, I willingly agree to participate in this open-ended interview that will investigate my experiences as a member of the Kuwaiti community. I agree to have this interview tape-recorded and I have received a copy of this consent form.

______Participant Signature Date

I have fully explained the participant‟s rights and answered all questions.

______Interviewer Signature Date

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Appendix D Interview Protocol: Mental Health Professionals Request participant to sign two copies of the information and consent form after reading. Explain that this interview is completely confidential. Explain their right withdraw from the study at any point during or after the interview (should they chose to withdraw, all data and any information pertaining to them or their interview, including all recordings and transcripts will be destroyed permanently). Ask for permission to record the interview and take notes, and let the participant know that they have full right to not answer any question and can pause the interview at any time. 1) Life history data: Tell me a little bit about some important events that have had a significant impact on your life, so I can get to know you better… a. What made you decide to pursue mental health as a profession? b. Tell me about your education background (where did you earn your degree/s and what in) c. How long have you been in Kuwait and what made you decide to work here? - Have you practiced anywhere else in the world? If yes, where? d. What is your specific area of interest / speciality (e.g. children, adults, phobias, PTSD, etc…)

2) Think of me as knowing absolutely nothing about Kuwait… What do you feel are the most important aspects of Kuwaiti culture? a. What do you like about it? b. What don‘t you like about it? c. How do you compare it to other cultures you have experienced?

3) Attitudes towards health a. What does ―health‖ mean to you? b. What does ―mental health‖ mean to you? c. What does ―mental illness‖ mean to you?

4) Experiences related to work life a. Tell me about a successful day in your work life - What made it a success? b. Tell me about a bad day in your work life - What made it so difficult?

5) Tell me about mental health practice in Kuwait a. What are some of the best aspects of working in Kuwait? b. What are some of the worst aspects of working in Kuwait? c. If you don‘t mind me asking, what types of cases are most frequent among your patients/clients? - What are the most worrisome issues you come across? - If any, what mental health issues do you feel need to be most addressed in Kuwait?

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d. In what ways does cultural similarity/dissimilarity affect your interactions with your clients/patients?

6) Contributors to mental health and illness in Kuwait a. How does Kuwaiti culture impact the practice of mental health? b. Are there any mental health issues you feel are specific to Kuwaitis or people in the Middle East in General? - If yes, what is the source of this? c. What are some of the cultural aspects of Kuwait that improve mental health? d. If any, what are some cultural aspects of Kuwait that increase mental illness? e. Are there any intergenerational differences in mental health/illness in Kuwait? - If yes, what are they? f. Are there any gender differences in mental health/illness in Kuwait? - If yes, what are they?

7) (If applicable – i.e. if they have practiced other countries other than Kuwait) What can you tell me about the similarities and differences of mental health issues in Kuwait and [other country/ies they have practiced in] a. Are there any issues in Kuwait that are more/less frequent than other countries? b. How do certain disorders look similar and/or different in Kuwait than other countries? - Are there any diagnoses that are difficult/easier to make in Kuwait compared to other countries? 1. If yes, why do you think that is? 2. How do you modify your practice to account for this difference? c. What are some of the cultural factors in Kuwait that protect individuals from mental illness? d. Are there any cultural factors in Kuwait that make some individuals susceptible to mental illness? - What are they? e. Tell me about some of the problems you face providing mental health care in Kuwait

8) What can you tell me about mental health policies in Kuwait? a. What can you tell me about the similarities and/or differences between mental health care in the public and private sectors? b. How do the current policies help and/or hinder your role as a mental health professional? - How do you feel about this? c. What culturally specific mental health policies do you think need to be made in Kuwait? d. If you had the ultimate power to organize structures and policies for changing mental health care in Kuwait, what would they look like?

9) Is there anything else you would like to share with me? a. May I contact you in the future if I have any questions?

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Appendix E Interview Protocol: Clients and Patients Request participant to sign two copies of the information and consent form after reading. Explain that this interview is completely confidential. Explain their right withdraw from the study at any point during or after the interview (should they chose to withdraw, all data and any information pertaining to them or their interview, including all recordings and transcripts will be destroyed permanently). Ask for permission to record the interview and take notes, and let the participant know that they have full right to not answer any question and can pause the interview at any time.

1) Life history data: Tell me a little bit about some important events that have had a significant impact on your life, so I can get to know you better… a. Age, education background.. b. How long have you been in Kuwait? - How do you feel about living in Kuwait?

3) Attitudes towards health a. What does ―health‖ mean to you? b. What does ―mental health‖ mean to you? c. What does ―mental illness‖ mean to you?

4) What can you tell me about mental health in the context of Kuwaiti culture? a. What are the general perceptions of mental health and illness in Kuwait? b. What are your perceptions of mental health and illness in Kuwait? c. Is there anything about Kuwaiti culture that promotes/inhibits mental health?

5) If you don‘t mind me asking, what can you tell me about your experiences with mental health care in Kuwait? a. How long have you been seeing a therapist? - What is their area of specialization (social worker, psychiatrist, clinical psychologist, or counselor?) 1. In what ways do you feel their cultural background shapes your interactions with them? - If you don‘t mind me asking, what is/was your therapist helping you with? - Have you told anyone else about your experiences with mental health care? 1. If yes, how did the conversation go?

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b. What can you tell me about the similarities and/or differences between mental health care in the public and private sectors? - How did you choose your therapist? c. How comfortable do you feel with your therapist? d. Has your therapist ever said or done anything that made you uncomfortable? - If yes, what happened, and how did this make you feel?

6) Tell me about a successful day in your life a. What did it look like?

7) Tell me about a bad day in your life a. What did it look like?

8) Contributors to mental health and illness in Kuwait a. How does Kuwaiti culture impact seeking mental health care? b. Are there any mental health issues you feel are specific to Kuwaitis or people in the Middle East in General? - If yes, what is the source of this? c. What are some of the cultural aspects of Kuwait that improve mental health? d. If any, what are some cultural aspects of Kuwait that increase mental illness? e. Are there any intergenerational differences in mental health/illness in Kuwait? - If yes, what are they? f. Are there any gender differences in mental health/illness in Kuwait? - If yes, what are they?

9) Are you aware of any policies or laws surrounding mental health care in Kuwait? a. What culturally specific mental health policies do you think need to be made in Kuwait? b. If you had the ultimate power to organize structures and policies for changing mental health care in Kuwait, what would they look like?

10) Is there anything else you would like to share with me? a. May I contact you in the future if I have any questions?

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Appendix F Interview Protocol: Kuwait Community Members Request participant to sign two copies of the information and consent form after reading. Explain that this interview is completely confidential. Explain their right withdraw from the study at any point during or after the interview (should they chose to withdraw, all data and any information pertaining to them or their interview, including all recordings and transcripts will be destroyed permanently). Ask for permission to record the interview and take notes, and let the participant know that they have full right to not answer any question and can pause the interview at any time.

3) Attitudes towards health a. What does ―health‖ mean to you? b. What does ―mental health‖ mean to you? c. What does ―mental illness‖ mean to you?

4) What can you tell me about mental health in the context of Kuwaiti culture? a. What are the general perceptions of mental health and illness in Kuwait? b. Is there anything about Kuwaiti culture that promotes/inhibits mental health?

5) Contributors to mental health and illness in Kuwait a. How does Kuwaiti culture impact seeking mental health care? b. Are there any mental health issues you feel are specific to Kuwaitis or people in the Middle East in General? - If yes, what is the source of this? c. What are some of the cultural aspects of Kuwait that improve mental health? d. If any, what are some cultural aspects of Kuwait that increase mental illness? e. Are there any intergenerational differences in mental health/illness in Kuwait? - If yes, what are they? f. Are there any gender differences in mental health/illness in Kuwait? - If yes, what are they?

6) Are you aware of any policies or laws surrounding mental health care in Kuwait?

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a. What culturally specific mental health policies do you think need to be made in Kuwait? b. If you had the ultimate power to organize structures and policies for changing mental health care in Kuwait, what would they look like?

7) Is there anything else you would like to share with me? a. May I contact you in the future if I have any questions?

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Appendix G

Feedback Letter: Mental health professionals

An Exploration of Mental Health, Illness, and Policies in Kuwait

Principal Investigator: Principal Supervisor: Neha Khullar Dr. Rory Coughlan Department of Psychology Department of Psychology Trent University Trent University Ph: (705) 761 8605 Ph: (705) 748-1011 ext 1079 e-mail: [email protected] e-mail: [email protected]

The researcher has conducted an open-ended, semi-structured interview to understand your experiences and opinions as a mental health professional in Kuwait. We hope that your participation will help us understand the general themes related to the experiences of being a mental health professional in Kuwait, as well as, if any, the policies and practices that you feel need to be modified in the mental health sector in Kuwait. Neither the researcher nor the research supervisor has any commercial interest in this or any other project. Although the research on this topic in Kuwait is relatively scant, some research indicates that a vast majority of professionals in the public sector are unlicensed. Additionally, research with Arab-Muslim clients and patients that utilize mental health services suggests that privacy and confidentiality are of upmost importance to them, and fear of confidentiality breaches is a significant contributor to individuals not utilizing mental health services (Hamid & Furnham, 2012). Lastly, it appears that is some stigma surrounding mental health care and that there is also lack of awareness of mental health care in Kuwait (Scull, Khullar, Al-Awadhi, & Erheim, 2013). Some studies have also shown that many health care professionals are experiencing severe burnout in the public sector, likely owing to a lack of training and governmental policies governing appropriate practices within the mental health sector in Kuwait. This may be the source of some of the unethical practices experienced by some individuals who have utilized these services in Kuwait (Scull et al., 2013). We hope that the current study will shed some extra light on effective policies and interventions required to improve mental health service delivery in Kuwait.