The role of culture in the perception and expression of stress and distress: experience from Oman

1. The role of culture in the perception and expression of stress and distress: experience from Oman Samir Al-Adawi Associate Professor College of Medicine &Health Sciences, Sultan Qaboos University

2. Sultan Qaboos University

3. What is Stress? • Pioneering studiesby Hans Selye in the 1960’s laid foundation for modern conception of stress • Stress refers to events that are perceived as endangering one’s physical or emotional wellbeing Selye H (1978) The stress of life (New York: McGraw-Hill)

4. Eustress (good stress)Distress (unhealthy stress)

5. Interim Questions Could events that are perceived as endangering one’s physical or emotional wellbeing lead to distress? The American Institute of Stress have reported that 75% to 90% of all hospital visits are stress-related. Could perception be shaped by socio-cultural factor? Could stress and distress be experienced in socio-cultural context?

6. AIMS This session will: • Focus on cultural patterning and social behavior in Oman • Highlight how distress is narrated among Omanis • Highlight good practice guideline relevant to Oman

7. Aim 1: Focus on cultural patterning and social behavior in Oman QEUSTION: How individual is socialized in Oman?

8. Cultural patterning and social behavior in Oman Dwairy et al.(in press). Parenting styles, individuation, and mental health of Arab adolescents: A third cross-regional research study. Journal of Cross-cultural Psychology. Parenting style ACTIVE PASSIVE UNINVOLVED

9. Collectivesocial orientation Oriented towards group affiliation and interdependence Individualistic social orientation Cultural patterning and social behavior in Oman Arab vs. Western societies

10. Cultural patterning and social behavior in Oman

11. Cultural patterning and social behavior in Oman

12. Aim 2: Highlight how distress is narrated among Omanis QUESTION: How stress and distressis experienced in Oman?

13. Some people isolate themselves and ruminate over the problem Some people distract themselves (e.g. by exercising) Some avoid the problem by resorting to harmful behavior such as excessive drinking When confronted with negative emotions How effective is each of these behavior?

15. Shame vs. Guilt When a social impropriety occurs in Oman: - An individual feels “ashamed," suggesting that his or her feelings are controlled by the perceptions of others. When a social impropriety occurs elsewhere: - An individual will experience sense of "guilt” resulting from intra-psychic conflict between one's behavior and one's self. How stress and distressis experienced in Oman?

16. How stress and distressis experienced in Oman? The avoidance of self-disclosure Many colloquialisms suggest caution regarding verbal expression. • “Tour tongue is like your horse, if you watch over it, it will watch over you." • “Complaining to anyone other than God is a disgrace“ • "The walk can hear" Avoidance associated with emotional material

17. How stress and distressis experienced in Oman? Depending on the level of education, distresses are attributed to sensate agents/external forces. Wasta Magic Evil Eyes Hasad

18. Untimely death “Zombies in Oman” The Mu Ghayeb belief in Omani society involves a complete denial of the loss for a relatively long period with the expectation of the return of the dead. Al-Adawi S, Burjorjee RN, Al-Issa I (1997). Mu Ghayeb: A culture-specific response to bereavement in Oman. INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY, 43, 144-151.

19. Distress experienced in consistent with cultural teaching ‘Active’ parenting within an collective culture is not as harmful as within a liberal culture. AL LAWATI J. et al. (2000). Psychological morbidity in primary healthcare in Oman: A preliminary study. Journal for Scientific Research: Medical Sciences, 2, 105–10. KOUSSOUS KJ. & AL-ADAWI S. (in press). Suicide in sultanate of Oman: descriptive study among Omanis and expatriates. Journal for Scientific Research: Medical Sciences. Zaidan ZAJ. et al. (in press). Hazardous and harmful alcohol consumption among non-psychotic psychiatric clinic attendees in Oman. International Journal of Mental Health and Addiction. ZAIDAN ZAJ. ET AL. (in press). Hazardous and harmful alcohol consumption among non-psychotic psychiatric clinic attendees in Oman. International Journal of Mental Health and Addiction

20. Gender vulnerability to stress and distress Insignificant gender gap in education and social empowerment Over 30% of the labour force in the government sectors are females

21. Gender vulnerability to stress and distress Data suggest that females with lower educational levels, married or divorced women have significant risk factor for feeling ‘burned out’ at the workplace.On the whole, females do better than males. Males are likely to develop stress-induced physical illness than female counterpart.AL-RIYAMI K. (2006). OCCUPATIONAL STRESS IN OMAN. Unpublished Master Thesis, Submitted to Business School, University of Glamorgan, UK

22. Work vs. Home stress Work-stress Home-stress

23. Possible predisposing factors leading to distress at occupational settings

24. Major changes in life circumstances • “Money from oil has brought Omanis progress through development in less than 20 years, development that took a thousand years in Europe” • Smith (Lancet, 1988)

25. CULTURAL CONSTRAINS AND MODERNITY

26. CHANGING GOALPOST • “Omanis tend to regard …the ability to seek higher social ….. as an acquired right” (Skeet,1992) • “there are too many Ph.Ds and too few mechanics” (Looney, 1994)

27. CHANGING GOALPOST The 17-item Effort-reward Imbalance (Siegrist, 2002) on Omani sample suggests 35% perceived themselves ‘putting more and receiving less’ AL-RIYAMI K. (2006). Occupational Stress in Oman. Unpublished Master Thesis, Submitted to Business School, University of Glamorgan, UK

28. ‘Perceived threat’

29. AIM 3: Highlight good practice guideline relevant to Oman Question: What can be done?

30. Organizational burdens due to stress 150 billion of revenue is lost to stress annually in poor decision making, stress related mental illness and substance abuse(National Occupational Research Agenda: Priorities for the 21st century. Washington DC, 200). • Stress-related illnesses entaillower productivity • Stress-related illnessesincrease sick leaves • Stress-related illnesses often result in early retirements • Stress-related illnesses often result in huge staff replacement cost

31. Global Burden of Diseases • World Health Organization • World Bank • NGOs Years of life lost by premature death Years of life lived with a disability of known severity The World Health Organization estimates that stress-related disorders will be one of the leading cause of disabilities by the year 2020

32. What is stress? 68% = ‘bad day’ 57% = “too much to do” 64% = “ an illness” Burnout syndrome Adjustment vs. Maladjustment GOOD PRACTICE GUIDELINE 1: Standardization of taxonomy Do not ‘medicalize’ maladjustment at workplace

33. GOOD PRACTICE GUIDELINE 2: Identify and quantify the magnitude of maladjustment Identify source of maladjustment within theorganization Quantify magnitude of maladjustment at workplace Lack of validity of assessment measures • Al-Adawi S et al, (2004). Apathy and Depression in Cross-Cultural Survivors of Traumatic Brain Injury. Journal of Neuropsychiatry & Clinical Neurosciences, 16, 435-442. • Al-Adawi S et al. (2002). A survey of anorexia nervosa using the Arabic version of the EAT-26 and "gold standard" interviews among Omani adolescents. Eating andWeight Disorders, 7, 304-311.

34. GOOD PRACTICE GUIDELINE 3: cease perpetuating maladjustment Current focus on ‘performance appraisal’ should be matched with ‘art of living’ Rewarding those individuals whose lifestyles keep maladjustment away

35. GOOD PRACTICE GUIDELINE 4: Devise counseling at workplace using trained experts • Anthrotherapist: • A person who is very well acquainted with the social structure and use that knowledge to mediate between the workplace and individual's wellbeing Traditional cultural identity Biculturally well-integrated identity Bicultural unintegrated identity COCONUT(Assimilated -acculturated identity)

36. Conclusion Occupational health services were created in the 19th century as part of social measures to counter-balance the negative effect of industrial revolution (Froneberg, 2006). • Initial focus has been on work-related accidents and improving quality of life • The disability caused by stress is just as serious as the disability caused by workplace accidents or traditional ‘enemy’ such as malnutrition and infectitious diseases. • Available view on maladjustment is derived from Euro-American population -20% of the world population. • Culture-sensitive approach to occupational health services would be essential in this era of globalization and to promote pluralism within globalization • Modern organization requires those who can work with others. Social behavior in Oman is congruent with such view.

37. Rock Sand Water Self-Evaluation: Topography of Oman Topographical features of Oman and stress

38. Topographical features of Oman and stress Rock-type • As if writing your problems in the rock, you give way to problems and retain them for a long time Sand-type • As if writing your problems in the sand, you give way to disappointment but the disappointment quickly passes away Fallaj/Wadi-type • As if writing your problems in running water, always remains pure and undisturbed.

39. THANK YOU!

40. Acknowledgment AL-ADAWI S et al. (2005). Japanese Journal of Psychosomatic Medicine, 45, 933-941. AL-ADAWI S, BURJORJEE RN, AL-ISSA I (1997). International Journal of Social Psychiatry, 43, 144-151. Al-Adawi S. et al. (2004). Journal of Neuropsychiatry & Clinical Neurosciences, 16, 435-442. AL-ADAWI S. et al. (2005). New Developments in Eating Disorders Research. New York: Nova Science Publishers. AL-BUSAIDI ZQ (2005). Rethinking Somatisation: The Attitudes and Beliefs about Mental Health in Omani Women and their General Practitioners. Unpublished PhD Thesis, School for Community Health, Division of Psychiatry, University of Nottingham. AL-HINAI SS. et al. (2006). College Students: Mental Health and Coping strategies. New York Nova Science Publishers. AL-LAWATI J. et al. (2000). Journal for Scientific Research: Medical Sciences, 2, 105–10. AL-RIYAMI K. (2006). OCCUPATIONAL STRESS IN OMAN. Unpublished Master Thesis, Submitted to Business School, University of Glamorgan, UK. DWAIRY M & VANSICKLE TD. (1996). Clinical Psychology Review, 16, 231-249. IVEY, AE & SUE, DW (2006). Multicultural foundation of psychology and counseling. New York: Teachers Colleges Press. KOUSSOUS KJ. & AL-ADAWI S. (in press). Journal for Scientific Research: Medical Sciences. SAKAMOTO et al. (2005). International Journal of Psychiatry in Medicine, 35, 191-198. ZAIDAN ZAJ. et al. (in press). International Journal of Mental Health and Addiction.