Patterns and factors associated with consulting traditional healers on the care pathway of psychiatric patients in the United Arab Emirates

Abstract

Background:

Despite the availability of mental health services in the United Arab Emirates (UAE), reluctance in seeking a mental health professional is widely prevalent. In many countries, psychiatric patients consult Traditional Healers (THs) prior to seeing mental health professionals. Data from the UAE on the pattern of consulting THs is limited.

Aims:

To investigate patterns and factors for visiting THs in psychiatric patients in Abu Dhabi, the capital of UAE.

Method:

We conducted a cross-sectional study of patients attending the adult psychiatry clinic, Maudsley Health, Abu Dhabi. We assessed 214 patients for the pattern and possible factors for contact with THs on their pathway to psychiatric care.

Results:

There were 58 males and 156 females. Most (43.5%) had a depressive disorder. Prior to consulting a mental health professional, 28% had seen a TH, of whom 36.7% had only one visit and 60% had seen only one TH. Advice from a friend or family member was the commonest reason for consulting THs (81.7%). Envy was the commonest explanation given by THs for symptoms (26.7%). Female gender and having a high school education or less significantly predicted contact with THs.

Conclusions:

Almost a third of our sample consulted THs prior to seeking psychiatric care. Closer collaboration with THs could help bridge the gap with psychiatrists to avoid delays in patients accessing psychiatric care, however caution is needed to mitigate the possible negative effects of such a collaboration.

Keywords

Traditional healers psychiatric disorders pathway to care United Arab Emirates

Introduction

Access to mental healthcare is one of the greatest public health challenges in low- and middle-income countries (LMICs), with an estimated 76% to 85% of people with severe mental illness in these countries receiving no treatment for their disorder (World Health Organization [WHO], 2021). Barriers to accessing mental healthcare include the centralization of services in urban areas at the expense of rural areas, a lack of funding and availability of trained medical professionals and a lack of prioritization of mental health in the public health agenda (Saraceno et al., 2007). Given these and other barriers (such as affordability of care), it is not surprising that the majority of patients with mental illnesses in these countries prefer to resort to traditional medicine (TM) and traditional healers (TH) for their needs (Assad et al., 2015).

Traditional medicine is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, used in the maintenance of health and in the prevention, diagnosis, improvement, or treatment of physical and mental illness (WHO, 2013). The diagnosis and treatment of an illness using traditional medicine is mostly culture-specific and based on beliefs in the community (Mbwayo et al., 2013). The popularity of traditional healers is due to a number of reasons: confidence in the explanations offered for the cause of illness (which can be more acceptable than conventional medicine) and in the traditional healers’ ability to understand patients’ illness experience within their cultural framework; affordability; and accessibility of traditional healers especially in remote areas where hospital facilities are lacking (Green & Colucci, 2020; WHO, 2002).

The relationship between conventional medical and traditional forms of care has historically been tense, because of their diametrically different understandings of illness (Calabrese, 2013). Mental health patients tend to pass through different healthcare-providing filters before reaching appropriate services. Therefore, a real challenge facing mental health professionals in LMICs, is in reaching those patients, who because they see traditional healers as their first point of contact, may be delayed in reaching mental health services, with implications for their prognosis and long-term outcomes (Assad et al., 2015). It was widely believed that patients’ use of THs simply reflected a lack of an alternative (i.e. conventional medical care), but more recently it has been demonstrated that THs are resorted to even when conventional medical facilities are available. This is particularly true of mental illnesses, where social and cultural determinants play a heightened role (Green & Colucci, 2020).

In most Arab countries there is no interaction between mainstream medicine and THs. Because prevailing cultural beliefs about the supernatural (e.g. possession, sorcery, evil eye) affect patients and their family’s interpretation of symptoms of mental illness, THs are usually the first resort when seeking treatment because of their claims to be able to deal with the mystical and the unknown, and who therefore form part of the informal healthcare sector by providing a form of religious-based intervention, especially where there is limited access to mental health services (A. Okasha, 1999; A. Okasha et al., 2012). In Arab culture, individuals may not seek proper professional help for fear of it being seen as a sign of weakness (Al-Darmaki, 2003). In addition, a lack of the awareness of the availability of mental health services and the stigma of seeking psychological help may impact help-seeking behavior (Sayed, 2015). Data from Arabic-speaking countries in the Middle East on rates of psychiatric patients who seek THs for their disorder varies from 34.1% in Tunisia for (Khiari et al., 2019), to between 39.8% and41.8% in Egypt (39.8% in obsessive compulsive disorder, 40.8% in bipolar disorder, and 41.8% in schizophrenia) (Assad et al., 2015; Awaad et al., 2020; T. Okasha et al., 2021), to 57% in Iraq (Younis et al. 2019), to 70.5% in Saudi Arabia (Sayed et al., 1999).

The United Arab Emirates (UAE) was formed in 1971 as a federation of seven states on the eastern coast of the Arabian Peninsula, where in the past few decades commercial exploitation of oil has allowed the UAE to transform itself from relative poverty to widespread affluence which has allowed for a dramatic improvement in living standards (WHO, 2006a). The welfare, health, prosperity, and life satisfaction of UAE citizens are directly linked to overwhelming social change which has required the accommodation of modern western culture with a conservative Islamic society. With rapid urbanization and significant societal changes, there has been a rise in mental health concerns (Chowdhury, 2016).

The UAE’s wealth and political commitment to comprehensive healthcare for all, has facilitated the rapid development of a modern healthcare infrastructure, inclusive of mental health services (WHO, 2006b). Alongside these conventional mental health services exists a traditional approach based largely on Islamic sources. The practitioners of this traditional approach are known locally as ‘mutawas’. There is no formal institutional qualification to become a mutawa and their practices are not officially licensed in the UAE. Some may have completed degrees at established Islamic universities but many will have earned their reputation through private study with recognized scholars (Makdisi, 1981). Mutawas employ non-medical, non-psychological methods of treatment such as using readings from the Qur’an and traditional medicine. Prior to 1971, this was the only known method of treatment for mental illness in the UAE (Al-Darmaki, 2004), and it involves driving out the ‘evil spirit’ or driving away the ‘evil eye’ to cure illness. This belief comes from the Arabic conceptualization of mental illness as being due to genies (jinns), the evil eye (‘ayn), sorcery (sihr), or envy (hasad) (Chowdhury, 2016; Sayed et al., 1998).

Despite the affluence of the UAE and the availability of mental health services (especially in urban areas), reluctance in seeking a mental health professional is widely prevalent even amongst the educated where the stigma attached to mental illness may simply be too much to bear (Sayed, 2015), and resorting to a mutawas is widespread (Thomas et al., 2015). Although modern medical practices are widely accepted in the UAE, it is observed that many people would consider this traditional method of healing over medical or psychological treatment because of its acceptability in the society and the prevailing belief of the ‘possession’ of the ill. Also, because culturally mental illnesses are considered by many to be a sign of weakness in the individual’s faith, many believe that by strengthening the relationship of the patient with Allah through prayers and readings from the Qur’an, psychological comfort, peace of mind, and relief of symptoms can be achieved. Therefore, psychiatric treatment might only be considered as a last resort or when severe psychopathology is apparent (Sayed, 2015).

Looking at how different psychiatric disorders engage with THs prior to seeking mental health services is important considering that visiting THs causes delays in patients reaching mental health services, with implications for prognosis and longer-term outcomes (Assad et al., 2015). Similarly, being involved with THs predicts non-adherence to medications in patients after discharge from hospital (Abdel Aziz et al., 2016). Therefore, there is a need to identify patterns and reasons for why patients visit THs, which may help identify how mental health services can bridge the gap between THs and conventional medical care, and also to identify strengths in the approach used by THs that could possibly be incorporated into mainstream mental health care for the benefit of patients.

To date, data from the UAE on the role of THs on the pathway to psychiatric care is limited. One UAE study by Salem et al. (2009) in Al-Ain city investigated help-seeking behavior in 106 psychiatric outpatients and found that 44.8% had engaged with THs before seeking medical services. A more recent UAE study by Sherra et al. (2017) in Dubai in bipolar patients found that 61.7% had seen a TH prior to engagement with mental health services. Given the sample size of Salem et al.’s study (N = 106), and that Sherra et al. only investigated bipolar patients, we sought to investigate the pattern of visiting THs in a larger sample of subjects with heterogenous psychiatric disorders attending an outpatient psychiatric service in Abu Dhabi, the capital city of the UAE, where no previous similar studies have been conducted. In addition, we also sought to investigate whether specific demographic factors and diagnoses predicted whether patients consulted THs prior to seeing a psychiatrist, which had not been carried out by the other studies in the UAE, both of which were descriptive studies. This will help understand the general picture of THs on the pathway to psychiatric care and inform the next step of establishing the extent of how common visiting THs is in larger samples of individual psychiatric disorders in the UAE. We hypothesized that a significant number of patients will have consulted a TH and that this would be associated with specific diagnoses.

Method

Subjects were recruited from the General Adult Psychiatry outpatient clinic at Maudsley Health in Abu Dhabi, United Arab Emirates. Maudsley Health is part of South London and Maudsley NHS Foundation Trust (the Maudsley) in the United Kingdom and was founded in 2013 as a collaboration between the Maudsley (the oldest psychiatric institution in the world) and MACANI Medical Centre, an Abu Dhabi-based organization, with MACANI employing and managing the staff and the Maudsley providing clinical quality assurance (South London and Maudsley NHS Trust Foundation, 2022). Founded in 2017, the Adult Mental Health Service is well-developed and consists of an outpatient team serving a patient population of 612 (Maudsley Health, 2022). The facility serves the population of Abu Dhabi (capital city of the UAE) and the surrounding towns, of around 1,074,415 people (World Population Review, 2022). It also accepts patients from other regions of the UAE. In our study we included male and female subjects attending the adult outpatient clinic, aged 18 to 65 years, of any nationality and who had an established psychiatric diagnosis according to DSM 5 (American Psychiatric Association, 2013). Subjects were excluded if they were less than 18 or older than 65 years, if they did not have a psychiatric diagnosis or if they presented to the clinic with an acute crisis or emergency. Data was collected for each subject’s demographic characteristics (age, gender, nationality, marital status, employment status, and level of education), psychiatric diagnosis and information about pattern of contact with traditional healers (frequency of visits, number of THs visited, reasons for visiting a TH, explanation given for symptoms, whether they paid for visiting a TH, whether they noticed an improvement after visiting a TH, and whether they would recommend to others visiting a TH).

Ethical approval for the study was granted by the American Center for Psychiatry and Neurology Institutional Review Board (IRB reference: 0047/10-08-2021). All those meeting the inclusion criteria and consenting to participate were included. A total of 214 subjects were recruited during the period between September 2021 and March 2022. The purpose of the study was fully explained to all participants. Prior to participation, patients were asked to sign a consent form confirming their understanding of the details of the study, after these were explained to them. Patients were advised that participation was totally voluntary, that their information would be kept confidential and used only for scientific purposes and that no identifiable patient information will be disclosed. Patients were also advised that they could withdraw at any time without giving any explanation, and that this would not affect the care they received. Data on demographics, diagnosis, and pattern of contact with THs were then collected.

For statistical analysis, data was analyzed using the IBM statistical package of social sciences (SPSS) version 28.0 for Windows (2021). Results were tabulated, grouped, and statistically analyzed using the following tests: mean and standard deviation (SD) for parametric numerical (quantitative) data, or median and range for non-parametric data; frequency and percentage for non-numerical (qualitative) data; chi-square test for comparing categorical variables or Fisher Exact-test when the expected frequency was <5; independent-sample student t-test to compare means. Logistic regression was used to investigate a dependent variable based on its relationship with a set of independent variables. A p value of <.05 was considered statistically significant.

Results

Demographic characteristics and diagnoses

Of the 214 subjects who participated in the study, 58 were male (27.1%) and 156 were female (72.9%). Sixty subjects (28%) reported visiting a traditional healer prior to visiting a psychiatrist or mental health professional, while 154 subjects (72%) did not. Table 1 summarizes the demographic characteristics and diagnoses of all subjects, as well as subjects who visited and didn’t visit traditional healers prior to seeing a psychiatrist or mental health professional. This shows a statistically significant difference between those who visited and didn’t visit traditional healers in terms of the gender and education. There was no statistically significant difference between the two groups in terms of age, nationality, employment status, marital status, and the diagnosis of the patient. The most common diagnosis in those who visited traditional healers was depressive disorder (N = 31), followed by anxiety disorder (N = 10), then mixed anxiety and depressive disorder and ADHD (both N = 5). The most common diagnosis in those who did not visit traditional healers was depressive disorder (N = 62), followed by anxiety disorder and mixed anxiety and depressive disorder (both N = 27), then social anxiety and ADHD (both N = 10), then bipolar disorder (N = 8).

Table 1.

Demographic and diagnostic characteristics for the whole sample, subjects who visited TH, and subjects who did not visited TH.

	All subjects (N = 214)	Visited TH (N = 60)	Did not visit TH (N = 154)	Test	p-Value
Mean age (SD)	27.60 (8.773)	27.68 (9.223)	27.56 (8.622)	t = 0.088	.465
	N (%)	N	N
Gender				χ² = 5.323	.021*
Male	58 (27.1)	23	35
Female	156 (72.9)	37	119
Nationality				χ² = 0.913	.339
UAE	177 (82.7)	52	125
Non-UAE	37 (17.3)	8	29
Education				χ² = 16.226	<.001*
High school or lower	31 (14.5)	18	13
University	142 (66.4)	33	109
Postgraduate	41 (19.2)	9	32
Employment				χ² = 1.155	.282
Employed	84 (39.3)	27	57
Unemployed	130 (60.7)	33	97
Marital status				Fisher = 8.822	.331
Single	143 (66.8)	40	103
Married	66 (30.8)	17	49
Divorced	5 (2.3)	3	2
Diagnosis				Fisher = 2.625	.245
Depressive disorder	93 (43.5)	31	62
Anxiety disorder	37 (17.3)	10	27
Mixed anxiety depression	32 (15.0)	5	27
Bipolar disorder	10 (4.7)	2	8
ADHD	15 (7.0)	5	10
Social anxiety	11 (5.1)	1	10
Adjustment disorder	6 (2.8)	2	4
OCD	5 (2.3)	3	2
Eating disorder	5 (2.3)	1	4

Note. UAE = United Arab Emirates; ADHD = attention deficit hyperactivity disorder; OCD = obsessive compulsive disorder; N = number; SD = standard deviation; t = student t-test; χ² = Chi-square; Fisher = Fisher Exact Test.

p statistically significant.

Pattern of traditional healers’ (THs) visits on the pathway to psychiatric care

Table 2 summarizes the pattern of traditional healer visits. Most patients visited the traditional healer only once (median = 2 visits, range = 1–8 visits), with 24 patients visiting more than one traditional healer (median = 2 THs, range = 1–6 THs). Advice from a friend or family member was cited as the most common reason for visiting a traditional healer, with envy followed by magic being cited as the most common explanation given by THs for the patient’s symptoms. Eighteen patients paid for their visit to the TH, with 9 patients noticing an improvement in symptoms and 16 patients saying they would recommend to others going to a TH.

Table 2.

Pattern of traditional healers’ (THs) visits among patients.

	N = 214	Percentage
Patients who visited a TH prior to seeing a mental health professional	60/214	28.0
Median number of visits to TH	2 (range: 1–8)	–
Frequency of visits to TH	N = 60	%
One visit	22	36.7
Two visits	10	16.7
Three visits	9	15.0
Four visits	5	8.3
Five visits	4	6.7
Six visits	2	3.3
Seven visits	2	3.3
Eight visits	1	1.7
Not reported	5	8.3
	N = 60	%
Patients who sought more than one TH	24	40
Median number of THs visited	2 (range: 2–6)	–
Number of THs visited	N = 24	%
Two THs	14	58.3
Three THs	6	25
Four THs	2	8.3
Five THs	1	4.2
Six THs	1	4.2
Reasons for visiting a TH	N = 60	%
Stigma of visiting a psychiatrist	3	5.0
Advice from a friend or family member	49	81.7
Not convinced they have a psychiatric disorder	3	5.0
Other	5	8.3
Explanation given for symptoms after visiting a TH	N = 60	%
Envy	16	26.7
Magic	15	25.0
Being possessed	6	10.0
Other	15	25.0
Not reported	8	13.3
Patients who paid money for visiting a TH	18/60	30.0
Patients who noticed improvement after visiting a TH	9/60	15.0
Patients who would recommend to others to visit a TH	16/60	26.7

Note. TH = traditional healer; N = number; % = percentage.

Demographic factors and diagnoses predicting use of THs

Logistic regression was carried out on demographic factors and diagnoses to evaluate whether these parameters were associated with visiting a TH in our sample (Table 3). The regression coefficient shows the effect of each variable after controlling the effect of other variables in the model. Female gender and having a high school education or less were significant predictors for visiting a TH. No specific diagnosis was a significant predictor for visiting a TH.

Table 3.

Factors predicting use of THs prior to seeing a psychiatrist.

	B	S.E.	O.R.	95% CI [Lower, Upper]	p-Value
Age	0.044	0.034	1.045	[0.977, 1.118]	.197
Female gender	1.265	0.450	3.543	[1.467, 8.556]	.005*
Nationality	0.625	0.519	1.869	[0.675, 5.172]	.229
High school education or less	−2.417	0.700	0.089	[0.023, 0.352]	<.001*
University education	−1.020	0.607	0.361	[0.110, 1.185]	.093
Employment status	0.612	0.423	1.845	[0.805, 4.225]	.148
Depressive disorder	−0.465	1.231	0.628	[0.056, 7.016]	.706
Anxiety disorder	−0.498	1.284	0.608	0.049, 7.528]	.698
Mixed anxiety depression	0.752	1.355	2.120	[0.149, 30.155]	.579
Bipolar disorder	−0.052	1.503	0.949	[0.050, 18.079]	.972
ADHD	0.007	1.357	1.007	[0.071, 14.390]	.996
Social anxiety	1.719	1.652	5.579	[0.219, 142.172]	.298
Adjustment disorder	−0.570	1.527	0.566	[0.028, 11.274]	.709
OCD	−1.615	1.651	0.199	[0.008, 5.055]	.328

Note. B = regression coefficient; SE = standard error of the coefficient; OR = odds ratio; 95% CI = 95% confidence interval; ADHD = attention deficit hyperactivity disorder; OCD = obsessive compulsive disorder.

p-Value is statistically significant.

Discussion

To date, few studies have investigated the role of traditional healers (THs) on the pathway to psychiatric care in the UAE. We found that 28% of participants reported visiting a TH prior to visiting a mental health professional. Major depression was the most common diagnosis in those who visited THs, and most visited only one TH and had only one visit. Advice from a friend or family member was cited as the most common reason for visiting a TH. Envy and magic were the most common explanations given for symptoms after visiting a TH. Only 15% of participants noticed an improvement after visiting a TH. Female gender and having a high school education or less were significant predictors for visiting a TH.

In our study, the rate of those who sought TH prior to presenting to psychiatric services (28%) was lower than other studies carried out in the UAE and the region. Salem et al. (2009) found that 44.8% of subjects consulted THs before presenting to psychiatric services. Their sample (N = 106) was smaller than our study but included a wider range of both psychotic and non-psychotic diagnoses. Sherra et al. (2017) found that 61.7% of subjects sought out a TH before seeking medical services in a sample of bipolar disorder patients. A possible explanation for the difference between our study and earlier UAE studies is that the earlier studies were conducted in government hospitals, while ours was conducted at a private psychiatric service. Therefore, there might be a difference between the types of patients who present to public and private psychiatric services, where it is more likely that patients presenting to private services represent a specific socio-economic stratum of patients who can afford to pay for their consultation fees, and excludes patients who are less well-off. However, the UAE runs an insurance-based healthcare system, where most people do not pay out of their pockets for medical care, although for mental healthcare this is more likely to occur with expatriates living in the UAE who receive variable levels of health insurance coverage which may not necessarily include mental healthcare (Abdel Aziz et al., 2020). For UAE nationals, every citizen is provided with full government-funded health insurance that grants access to both government and private healthcare providers (Mental Healthcare in the UAE, 2022). Therefore, the choice of service for UAE citizens, is unlikely to be affected by whether it private or public. This is relevant to our study, where 83% of participants were UAE nationals. In addition, over a third (around 37%) of psychiatrists in the UAE work in the private sector (all in outpatient services) and so constitute a significant portion of the country’s mental health workforce (UAE Ministry of Health and Prevention, 2022), and see a significant proportion of the psychiatric population. Therefore, although there are differences in rates between the types of services in the UAE, reporting these differences helps inform the overall picture of the role of THs in the pathway to psychiatric care in the UAE.

Studies from other countries in the region seem to suggest a trend toward higher rates than our study. In Egypt, Assad et al. (2015) found that 62.2% of subjects with bipolar disorder first sought advice from THs, while Awaad et al. (2020) found that 41.8% of schizophrenic patients first consulted THs, and T. Okasha et al. (2021) found that 37.8% of subjects with OCD first sought out THs. Differences in overall rates therefore could be attributed to the different diagnoses in the various samples, especially as our sample had few bipolar and OCD patients and no patients with psychotic disorders. But similar to our study, Salem et al. (2009) reported that the most common diagnosis in their sample was depression, followed by anxiety. Yet a significantly higher percentage of the patients in the study by Salem et al. with schizophrenia and bipolar disorder made contact with faith healers (62.5%), than those with a non-psychotic diagnosis (39.4%). Similarly, Campion and Bhugra (1997) reported that significantly higher rates of consulting THs were in found in patients with psychotic disorders (delusional disorders and schizophrenia).

However, our study found that no specific diagnosis was predictive of contact with THs, which was similar to Zingela et al. (2019) who also found that no specific diagnosis was predictive of contact with THs. Therefore, it is possible that differences in rates might be linked to the theme of psychopathology in each disorder rather than a specific diagnosis per se, for example patients seeking THs for religiously-themed symptoms, regardless of the diagnosis. Religion and prevailing traditions seem to color the clinical picture of psychiatric conditions which appear to be influenced by the patterns of religious emphasis in society (Atallah et al., 2001; A. Okasha, 2004). Grandiose symptoms of hyper-religiosity are well-known to occur during mania (Koenig et al., 2020) and rates of religious delusions and hallucinations in schizophrenia have reached as high as 63.3% in some studies (Grover et al., 2014). This may therefore explain why samples with higher numbers of subjects with psychotic and bipolar disorders have higher rates of seeking out THs. This is also true in non-psychotic disorders such as OCD, where 81.1% of subjects seeking THs report religious obsessions (T. Okasha et al., 2021) suggesting that when symptoms are associated with religious content, rates of consulting THs first are comparable to disorders such as schizophrenia (37.8% for OCD vs. 41.8% for schizophrenia) (Awaad et al., 2020; T. Okasha et al., 2021).

In other countries, rates of consulting traditional healers for psychiatric disorders varied considerably. A systematic review of 11 studies by Burns and Tomita (2015) looking at THs in four African countries (Ethiopia, Nigeria, South Africa, and Zimbabwe) found a mean of 48.1% of individuals first consulted traditional and religious healers in their pathway to psychiatric care. In Nepal, Pradhan et al. (2013) found that 35.2% of psychiatric patients visited faith healers as their first contact in seeking care. In Singapore, Chong et al. (2005) found that 24% of the respondents had sought help from traditional healers before consulting psychiatric services, which was comparable to our study, while in Malaysia the rate was 69% (Razali & Najib, 2000) and in Indonesia the rate was as high as 87% (Kurihara et al., 2006). Even in Europe and North America, around 50% of the population reported using complementary medicine at least once (WHO, 2003). In Germany, it was found that among psychiatric inpatients, 50% had used traditional or complementary medicine parallel to psychiatric treatment (Assion et al., 2007), and in Norway, it was found that 50% of the Sámi people of Northern Norway and 31% of Norwegians sought traditional or complementary medicine for psychological problems (Sexton & Sørlie, 2008).

Part of this wide variation in rates may be attributed to methodological differences between studies. For example, some studies reported any contact with THs while others only reported contact prior to psychiatric care. Some studies have reported on individual psychiatric diagnoses while others have investigated samples with a mixture of diagnoses, including non-psychiatric disorders. There are also issues with how THs are defined, with different studies sometimes highlighting distinctions between THs, religious healers, and complementary medicine, while others do not.

Another reason why rates may vary between countries is that in some countries traditional medicine may actually be the only affordable treatment available for poor people. In developing countries, up to 80% of the population depend on traditional medicine to help meet their healthcare needs (WHO, 2002), with THs forming an important source of psychiatric support in many parts of the world. This is because the numbers of THs in these communities are sufficient and their approach is acceptable to many people as they do not stigmatize mental illness, are willing to carry out home visits and offer a belief system that is parallel to conventional medicine regarding the origins and treatment of mental disorders (Ndetei, 2007; Ndetei et al., 2018).

Our study found that envy (26.7%) followed by magic (25%) were reported as the most common explanations given for the patient’s symptoms and only 10% reported possession as an explanation. Our findings were different from Awaad et al. (2020) who reported that black magic, genie possession, psychiatric illnesses, and then envy were the most frequent explanations given by THs for patients’ symptoms. Similarly, T. Okasha et al. (2021) reported that THs explanations for symptoms were mostly attributed to possession (78.4%), black magic (64.9%), and envy (45.9%). Awaad et al., 2020 only investigated subjects with schizophrenia and T. Okasha et al. (2021) only investigated subjects with OCD, so the different diagnoses might explain the difference from our study. In Arab culture, envy or the evil eye is where another person’s success attracts omnipotent, evil-producing wishes of the eyes of people who envy their success, and which are then held responsible for any deterioration in the envied person’s well-being (El-Islam, 1978). Anti-envy charms such as blue beads or hand gestures involving five fingers are implemented to counter the envying effects of the evil eye. Rituals endowed with anti-sorcery and anti-envy functions include the use of amulets containing Quranic verses, fumigation of incense, ritual visits to the tombs of religious sheikhs, and purification rituals that involve drinking or bathing in water that has had Quranic verses written on a plate that is washed off in them (Sherra et al., 2017).

Most participants in our study only had one visit to the TH (36.7%) and most only visited one TH (60%). This was similar to Awaad et al. (2020) who reported that 76.3% of subjects visited only one TH, but was different from T. Okasha et al. (2021) who found that 64.8% consulted multiple THs, and from Assad et al. (2015) who found that the most of their participants had four or more visits to the TH. It is possible that the low frequency of visits and consulting different THs in our study is related to a lack of perceived benefit from these visits for most of our participants, as only 15% reported noticing improvement after visiting a TH. Other studies reported a higher frequency of visits to THs where there was a higher rate of reported improvement. In South India, Campion and Bhugra (1997) reported that around 45% of subjects had between 1 and 15 visits with 30% reporting benefits from THs. Sherra et al. (2017) reported that 65% of subjects had more than one visit to THs with 49% reporting improvement or partial improvement from these visits.

Advice from a friend or family member was the most common reason in our study for visiting a TH. This was similar to T. Okasha et al. (2021) who reported that the most common reason for seeking THs (81.1%) was because of a recommendation by their family, followed by being unsure where to obtain treatment, then easy accessibility, then social acceptability, then the surrounding mental health services being unqualified, and lastly easily affordability. This was different from Awaad et al. (2020) who reported that advice from family and friends was only the fourth commonest reason for seeking THs, while social acceptability was the commonest reason, followed by affordability and then by ease of access to a TH. Although there is a strong Arab and Islamic cultural belief that adversity may be influenced by supernatural powers such as jinn and the devil (Sherra et al., 2017), the extent to which Arabs adhere to these beliefs and base their behavior on them varies a great deal from one Arab community to another (Al-Ansari et al., 1989), which might explain the differences between studies for the frequency and reasons patients seek THs. The acceptability of THs from society might be related to people’s fear of the stigma associated with the label of a psychological problem and for fear of others attributing this psychological problem to a lack of faith, making individuals more vulnerable to judgment by society. Hence, there may be a preference for attributing psychological problems to external factors such as possession or envy rather than to a mental illness (Sherra et al., 2017).

In our study, female gender was a significant predictor for visiting a TH. This is similar to Bell, Goebert, Miyamoto, et al. (2001) who also found that participation in native healing practices was predicted by female gender, as well as Pradhan et al. (2013) and Kapur (1979) who found that significantly more females approached THs than males. However, Assad et al. (2015), Razali and Najib (2000), and Bell, Goebert, Andrade, et al. (2001) found no gender differences in those consulting THs. Our finding therefore suggests that consultation with THs might be gender-related rather than a general societal attitude toward THs.

Our study found that having a high school education or less (but not a university education) significantly predicted whether THs were consulted prior to seeing a psychiatrist. This is consistent with several previous studies. Assad et al. (2015) found a positive correlation between low levels of education and consulting THs. In South Africa, Zingela et al. (2019) reported that having a lower level of education was a significant predictor for consulting THs as did another South African study by Sorsdahl et al. (2009) that found that individuals with little or no formal education were more likely to consult traditional healers than those who were more educated. Other studies, however have found no significant association between the educational level of patients and their pattern of help seeking behavior (Bell, Goebert, Andrade, et al., 2001; Razali & Najib, 2000).

There were several limitations to our study. Our study was a cross sectional study, which only allowed us to highlight associations, but not infer any causal relationships and also could have benefitted from a larger sample size, with more men participating. In addition, our sample was exclusively from an outpatient setting, so that patients with more severe presentations requiring hospitalization and who may have had longer delays in accessing medical care (and seen THs as an alternative) were not included. Also, as our setting was a private mental health service, some patient groups (e.g. expatriates without full mental healthcare insurance cover) may not have been represented. Nevertheless, as previously mentioned, private psychiatrists in the UAE represent over one third of the psychiatric workforce in the UAE and hence encounter a significant proportion of the psychiatry caseload. Other limitations include that we did not report findings according to different religious affiliations which would have helped further clarify trends in the use of THs. Unfortunately, for patient privacy reasons we were not permitted to collect this information.

Conclusions

We screened a large sample of heterogenous psychiatric patients for whether they had consulted with a TH prior to seeking psychiatric care. About a third of participants had a consulted a TH. Most had only one visit to the TH and most consulted only one TH and a minority (15%) reported improvement after seeing a TH. Advice from friends or family was the most common reason for consulting a TH. Envy and magic were the most common explanations given by THs for patient symptoms. Being female and having high school education or less predicted consultation of THs while age, nationality, employment status, and diagnosis did not. There may be advantages in closer collaboration between mainstream psychiatric care and THs, especially as regards the role that THs may play in the early identification of mental illnesses that may help reduce delays in patients reaching appropriate care. Despite different conceptualizations of mental illness, evidence suggests that both THs and medical practitioners recognize that patients can benefit from a combination of both practices and have demonstrated a willingness to work together (Green & Colucci, 2020). However, any such collaboration should proceed cautiously, given that there may be negative consequences from closer integration, given that many THs have no formal training to identify and treat mental illnesses. There have also been concerns about patients’ safety and human rights regarding some of the methods used by THs, as well as the skepticism of many THs about the effectiveness of modern psychiatric treatments which may interfere with the psychiatric care that patients receive (Green & Colucci, 2020; Ndetei et al., 2018). Future studies should look at investigating trends in larger samples of individual diagnoses to identify similarities and differences with previous studies and the possible role of religiously-themed symptoms in patients consulting THs.

Footnotes

Acknowledgements

The authors wish to thank Dr Khaled Kadry, Consultant Child and Adolescent Psychiatrist, Maudsley Health, Abu Dhabi, UAE and Ms. El Nada Mustafa, Assistant Psychologist, Maudsley Health, Abu Dhabi, UAE for supporting this project.

Author contributions

All authors were involved in the conception and design of the study and approved the final version of the paper. Shaden Adel, Dina El Tabei, Noha A Mahfouz were involved in the acquisition of the data and revising of the write-up. Karim Abdel Aziz and Dina Aly El-Gabry were involved in the statistical analysis and in writing the initial draft of the manuscript.

Data availability statement

Data is available upon request.

Conflict of interest

The authors report no conflict of interest.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Karim Abdel Aziz

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