Stigma, prejudice and discrimination: Mental health in Tunisian culture

When a person accumulates all the sorrows and sad experiences he has gone through since childhood, and buries them deep inside without sharing anything even to his closest relatives, appearing strong in front of them while donning a brave smile, sooner or later a day will come where he will burn out from the heavy burden he has endured alone. Only then would he admit his weakness and urgent need for help and for someone to listen to him with full attention.

This description applies to the case of the young Tunisian woman "Mariam" (pseudonym), who chose to hide her sorrows from her small family so that they wouldn’t suffer or have their feelings hurt, and decided to suffer mentally herself instead.

The family problems that Mariam, 27, experienced left her with scars that grew with her. These wounds have exacerbated after her committed relationship with her life partner (fiancé), whom she initially thought would be her lifeline from her suffering, but things changed over time.

Deciding to seek treatment

"I made the decision to see a psychiatrist because of the accumulations I have experienced since I was 5 years old. They were mainly due to the problems between my parents, and my great fear of their divorce, despite the lack of understanding between them due to my father's infidelity and my mother suffering from domestic abuse," she explains to Raseef22.

Mariam had a severe psychological breakdown after she and her mother learned that her father had filed for divorce for some time, and then made her second failed attempt to commit suicide.

During this sensitive period that she was going through, Mariam fell in love with someone, because she had found in him the tenderness that she was deprived of in her family. But with time, disputes began to arise between them, "I found myself in an incomprehensible relationship that changed and lost the eagerness it once had. I felt he had changed while my feelings and I remained the same," she says.

Mariam did not make the decision alone to see a psychiatrist for treatment. Her fiancé had encouraged her because he saw her psychological condition getting worse day after day, which reached the point of her suicide attempt, she adds.

She did not tell anyone the first time, fearing that her family would sense "her psychological suffering was in light of the problems they are going through", but her doctor asked her to inform them because her psychological condition requires great comfort and attention from her family, especially as the beginning of treatment was by taking medication due to her suffering from severe depression.

Mariam had a severe psychological breakdown after she and her mother learned that her father had filed for divorce for some time, and then made her second failed attempt to commit suicide

Mariam believes that it is necessary for everyone to see a psychiatrist from childhood, and to receive psychological care. She regrets that Tunisian society does not accept this idea and considers people with mental issues as "mentally deranged".

She confirms that she was ridiculed by some of her friends over getting treated by a psychiatrist, "but that did not affect me. I had a strong desire for treatment, to be able to advance in my life and to love myself."

She concludes, "I benefited a lot from my treatment at the psychiatrist, since it made me get used to being calm when I face difficult situations. I am not affected as quickly as before. I am still undergoing treatment and happy with what I have achieved with him."

"She is my little girl and my angel. I didn't think that this little angel would carry all these burdens alone. I take full responsibility for that," Salwa (pseudonym) tells Raseef22.

"Cyrine" (pseudonym) grew up in a family where her parents would fight night and day, from beatings to mutual cursing between her father and mother. She had a fragile and cold father-daughter relationship that reached the point of him preferring his other two daughters over her.

The earliest sign of her ongoing psychological issues up till now was her stuttering (dysphemia) as a child. But her parents did not pay attention to it at first. The traumas and pressures from childhood through adolescence continued to accumulate until she carried out her first failed suicide attempt.

This incident was shocking to Salwa, who was sure afterwards that her daughter was going through severe psychological problems. As a result, she made a decision to take her to a special psychiatrist for treatment, and she received quick acceptance and approval from her child.

Progress then relapse

Cyrine, 17, began responding to the treatment sessions at the psychiatrist and promised her mother that she would not be affected again by their family problems and that she would not reattempt suicide. She then stopped visiting the doctor with her mother, who felt her daughter getting better.

But then the escalation of family problems increased the psychological pressure on the teenage daughter, who later carried out a second failed suicide attempt, and dropped out of school despite excelling in her studies. Her relationship with her mother was also affected, and became based on disrespect and coldness.

In Tunisia, mental health issues are seen as a form of "madness", which results in daily suffering for many people

Salwa confirms that she doesn’t care about others' opinions of her daughter, and that her only concern is to get her little angel back and restore her psychological balance. She says that she will not abandon her despite the daughter refusing to go back to her psychological treatment, and that she will find a way to restore the happiness and mental comfort that she and her daughter have lost.

During the last ten years, Tunisian people have been experiencing major unstable political transformations that have cast a shadow on their worsening social and economic situation. Recently, this situation has only gotten worse with the increase of the rates of unemployment, poverty and irregular migration, which are witnessing unprecedented records among all segments of the population.

Official figures and studies confirm the gravity of mental disorders experienced by Tunisians, as the World Health Organization mentions in a study on mental illness in the African continent that 518,000 Tunisians suffer from depression, making Tunisia third in Africa.

According to the organization, the rate of demand for the use of sedative pills in Tunisia has reached 15%, while mental illness accounts for 98% of the causes of long sick leaves in the public service sector.

The Arab Barometer's study on mental health in the Middle East and North Africa ranked Tunisia among the societies most depressed, with a percentage of 40.

The 2021 Happiness Index issued by the Organixation for Economic Co-operation and Development (OECD) considered Tunisians as one of the least happy people in the world, with Tunisia ranking 166th globally according to this index.

"Mental health is like physical health. Sometimes, people go through normal stages and are in good health and at times they go through ups and downs," sociologist Latifa Tajouri explains to Raseef22.

"A curse from God"

She says that Tunisian society does not recognize mental illness, similar to European societies that had previously considered people with mental illness cursed and punished by God, so they used to lock them up and subject them to the most severe types of punishments.

She adds that societies, medicine, research and studies have evolved today, and that it has been discovered that mental illness is a set of disorders that can affect a person at all ages; childhood, adolescence, early adulthood and old age, and that it is not only related to inner personal causes but to external ones as well.

The demand for sedative pills in Tunisia reached 15%, while mental illness accounts for 98% of the causes of long sick leaves in the public service sector

However, browsing the websites of official Tunisian institutions concerned with the field of mental health, it is noticeable that they are interested in this area, as the Ministries of Health and Higher Education provide pupils, students and children with free visits to psychologists in their clinics in 11 governorates and in 10 other centers in 10 different governorates.

As for the Ministry of Women, it had provided a free green number for psychological consultations and seeking guidance under the supervision of psychologists.

Psychologist Abdul Baset al-Faqih asserts that the medical testimony provided by a psychiatrist in Tunisia is of great value and no one denies its impact and strength, "but are we working on the prevention of mental illness and taking care of mental health or not? That is the question at hand."

Lack of awareness

There is a lack of awareness in regards to the importance of mental health in Tunisian culture. One of the most important manifestations of that is the fights that happen between citizens in queues of bakeries and means of transportation, "which indicates the absence of prevention strategies and learning how to interact and deal during conflict and pressures in relationships. There is a big struggle in terms of recognizing the importance of mental health."

He strongly criticizes the stigmatization of those who are mentally ill with terms like "insanity" or "madness", and the bullying they are exposed to. He believes that the Tunisian social incubator does not address problems, but rather enjoys them. He calls for the need to review these behaviors, as the issue is cultural and we must recognize that the mental and psychological system gets sick like any other system in the body."

In his opinion, the problem lies in the lack of recognition of behavioral disorders by people, and in the absence of treatment by a certified psychiatrist. This is evidenced by the large numbers of people with official jobs who request sick leave certificates to rest from work without seeing psychiatrists to address and solve their problems.

The psychologist also cites the high numbers of marital problems and divorces resulting from them, the tension in relations between co-workers and between adolescents and their families, as well as the transformation of school into a space for elevated stress. He attributes this to the failure to address all these problems by psychiatrists, "This is evidence that tremendous work is still needed to help people reach a deep understanding of resorting to a psychologist."

Social stigma

For her part, Tajouri says that Tunisia is now keeping pace with the progress of research in the field of mental health, "but the difference lies in societal acceptance concerning the social stigma that pursues everyone who visits a psychiatrist."

Among some societal practices is encouraging people to see regular doctors rather than encouraging them to pursue psychological and behavioral self-development, "because it has not been sufficiently integrated into our culture and there is a stigma that pursues people with mental illnesses, especially in the family and professional fields," she stresses.

She also talks about the presence of "unnecessary fear of mental illnesses. Not every person who has a mental illness will do violent acts and react violently."

In her opinion, the danger lies in society's lack of acknowledgement of psychological treatment and in the recognition of mental illness as if it is a disease of the rest of the body.

To save individuals from depression and suicide, al-Faqih explains that families should seek the help of an experienced psychiatrist to address individuals' psychological problems, as the service of mental health professionals has spread today in regional hospitals, especially in major cities.

Family and school responsibility

Mental health care and believing in the legitimacy of mental illness begins in the family, because it is the circle in which all habits are established, such as adapting to solving problems and acquiring mechanisms to solve them. There, one must learn basic human reactions based on listening, understanding the other, accepting differences, and the basic principle of empathy among its members. Family members should be a refuge that victims can rely on and they shouldn’t exert pressure on them.

He points to the school's basic role, "in which a lot of injustice and bullying is practiced today," in creating conditions where its members stay mentally healthy, and stresses that these incubating institutions are required to properly deal with people with difficulties and ordinary disorders and to seek help from experts so that these disorders do not turn into serious mental illnesses.

Abdul Baset al-Faqih stresses the importance of people's recognition of their rights and the importance to defend these rights, to not be afraid and silent, as well as the need to neutralize the sources of pain, pressures, and problems, and learn to reject and say “no”.

The role of the government

For her part, the sociologist stresses that the government must first recognize the existence of mental illnesses and the field of mental health, "because we specialists today find it very difficult to prove the legitimacy of mental illnesses in the professional field (work spaces). All employees suffering from mental illnesses find themselves suffering from administrative stigma that disrupts their career just because they were once exposed at some point in their life to a psychological problem."

Latifa al-Tajouri assures that neglecting the mental health of pupils and students also affects the progression of their studies, especially in the absence of realistic programs and proximity services, "which we hope will be available in schools and nurseries under the supervision of specialists in psychology and sociology at various stages of development of adolescents, youth and the elderly."

She concludes, "Mental health is important from the time the fetus is in its mother's womb until the time of birth. Also, psychological care for pregnant women is obligatory during pregnancy and after birth."