For Fouzia, a Moroccan psychologist, the COVID-19 pandemic has shown her that remote therapy works. And it helps people feel safe — “especially those who want to be anonymous.”
Telehealth increases access to mental health care by allowing Fouzia and other providers to connect with people living in various circumstances. Some might not be able to afford travel. Others might have physical or mental health issues that would prevent an in-person meeting. And many appreciate the privacy that telehealth affords.
“For anyone, going to a psychologist is already quite a decision, because it [means] coming face to face with yourself and with your problems,” says Dounia, a Moroccan psychologist. “But it’s even more complicated for people who already suffer from stigma.”
Many of Fouzia’s and Dounia’s clients are people living with HIV — including members of the LGBTQ+ community — who can face discrimination and violence. “These stressors increase anxiety, depression, post-traumatic stress disorder and a range of other issues,” says Robyn Dayton, FHI 360 senior technical advisor. “And access to mental health care can positively impact HIV prevention, care and treatment outcomes, which can lead to improved physical health — and mental wellness.”
Connecting people to stigma-free mental health care
In the Middle East and North Africa (MENA) region, as in much of the world, people who inject drugs, sex workers, gay men and other men who have sex with men, and transgender people are more likely to be “marginalized, subjected to violence, and lack access to stigma-free and quality health care,” says Dayton.
Members of these communities are at higher risk of acquiring HIV and are sometimes called key populations by those working on HIV research, advocacy and programs. In 2019, more than 95% of new infections in the region occurred among members of key populations and their partners.
Since September 2021, FHI 360 and its partner, Pragma Corporation, have collaborated with 10 HIV service delivery organizations in the region to provide free, confidential, virtual mental health care through the MENA Moves project, funded by the U.S. Agency for International Development. The project created a website through which clients of and providers from these organizations in Tunisia, Morocco and Algeria can schedule appointments with trauma-informed, non-stigmatizing therapists. With the COVID-19 pandemic necessitating lockdowns and its ripple effects causing additional stress, the online format of the project garnered immediate interest.
“The pandemic has really accentuated the need for mental health support,” says Najib, who works for OPALS (or the Pan-African Organization for the Fight against AIDS), one of the service delivery organizations in Morocco. OPALS conducts awareness campaigns and offers medical, psychological and legal support to people living with HIV. “We regularly refer people to the website and help them book mental health care appointments,” says Najib. So far, nearly 3,000 sessions have been booked through the site.
While the pandemic has revealed the magnitude of the need for care — what Fouzi called “a wave that fell on us” — telehealth is increasing access for people, says Dounia. MENA Moves is helping “guarantee these people the right to health — but also, for some people, the right to life. There are people who told me only recently, ‘Before [therapy], I was thinking of killing myself.’”
Reaching “people who live with heavy burdens”
The pandemic “triggered a lot of psychological problems, a lot of anxiety, a lot of cases of depression — things that have come up to the surface,” says Dounia. She estimates that 70 to 80 people have booked appointments — most of which are recurring — with her this year through the website. Many of her clients feel isolated: They “really needed to talk to someone, to be listened to, to feel valued — to feel that they are seen by others.”
Dounia’s clients through MENA Moves include people at greater risk of contracting HIV as well as survivors of violence. “These are people who have suffered enormously in the society in which we live — from stigma, from discrimination. These are people who live with heavy burdens.” What comes up most in her conversations with clients, she says, is a feeling of, “‘I can’t be myself within society.’ They can’t even be themselves with their families.”
During lockdowns, her clients living with HIV would sometimes have trouble finding an excuse to leave the house to collect their medication, fearing that the people they lived with would learn of their HIV status. Khawla, a participating Tunisian psychologist, shares that, to help her clients avoid uncomfortable situations with family members or roommates, she sometimes recommends that her clients buy boxes of vitamins to store their HIV medication.
“You can trust her”
Virtual mental health care provides a sense of psychological safety that can be hard to find elsewhere, especially for those who have experienced stigma in the past. Aida, a participating Tunisian therapist, notes that, for some clients, it takes a few sessions for them to share personal details.
“There’s a relationship of trust that is established, when you have people finally say, ‘I do not live where I said at first — in fact, I live here, this is my real name, this is my birthday.’”
Aida tries to help her clients feel secure. The “most important thing is that I put you on a path that allows you to be in equilibrium,” she says. “When you’re mentally balanced, everything usually goes well.”
One of the people who sought care is Aziz*, a 22-year-old political science student who dreams of being a politician. They had tried therapy before, but they had a negative experience with a homophobic psychologist (Aziz is non-binary and identifies as gay).
“It’s really difficult to be queer in Tunisia,” they say (homosexuality is criminalized in the country, along with 70 other countries globally). They note that it is challenging to find a safe, comfortable space to be themselves. “It was a little bit difficult for me to come out in this society; I was a little bit discouraged.”
Through friends’ recommendations, they learned of the telehealth website. Aida explains that referrals by friends are common. “I had people call me, telling me a friend who was a client referred them. ‘It’s okay,’ they said. ‘I see a psychologist. You can talk to her; you can trust her. Everything will be private.’”
“I am even more myself now … I am more friends with myself”
For Aziz, therapy provided a sense of security. “I felt safe, to be honest,” they say. Their psychologist helped them build their self-esteem. “I am even more myself now. I developed many things in myself over the last six months … I am more friends with myself.”
Dounia knows how important it is for her clients to have someone to talk to. “They tell me, ‘I don’t talk about this with anyone else.’ These are people who don’t have a trustworthy person that they can count on, to talk about suffering, about normal life.”
She feels the positive changes in her clients, too. “I’m proud of every single person that I’ve met who has taken their health seriously and committed themselves [to therapy],” she says. “I’m proud of all the smiles that I’ve seen, when in the beginning all I saw were tears. I’m proud of all the people who were able to get back to life and have their symptoms slowly disappear.”
*Name has been changed. Illustration by Elwa Design for FHI 360.
