Take Care of Zizi, directed by Karim El Shennawy, 2021

Take care of Zizi, directed by Karim El Shennawy (2021), is an Egyptian television series that sensitively portrays Attention Deficit and Hyperactivity Disorder (ADHD). Zizi (Amina Khalil) is a recently divorced woman who is diagnosed with ADHD in her mid-thirties. An unexpected series of events between Zizi and her psychiatrist, Dr. Samy (Sabri Fawaz); her lawyer Mourad (Mohammed Mamdouh); and Tito (Reem Abdel Ghaffar), a nine-year-old girl with ADHD, enable Zizi to reflect on both her childhood trauma and dysfunctional marriage (Fig. 1).

Fig. 1
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ADHD brings Zizi (Amina Khalil) and Tito (Reem Abdel Ghaffar) closer together

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Clinical psychologist and script writer for the series, Mona El Shimi, commented on the audience’s extremely positive response: “[It] connected with the audience by portraying a subject that affects children and adults alike. In 2016 it was estimated that there were 6.1 million children diagnosed with ADHD in the USA. The global prevalence of ADHD is estimated to be around 7.2%. However, I do I believe that the actual prevalence of ADHD is much higher than what is quoted in the literature.”1

In addition to the critical acclaim and popular response, the series also generated controversy around the role of medications in ADHD. It polarised specialists with some stating that the series advocates for medical treatment, while others viewed it as a polemic denouncing ADHD medication altogether. El Shimi elaborates further:

The controversy happened because of Dr. Samy’s reluctance to use a pharmacological approach for ADHD symptoms. Later in the series, the viewer realizes that Dr Samy’s stance was driven by a personal trauma relating to his son committing suicide through an overdose of antidepressants. This background story explains Dr. Samy’s strong aversion to medications for mental illness. However, we do see two other professionals recommending medications for ADHD, Dr. Shendy and Dr. Nayera, who were managing Tito, the young girl with ADHD. It is important to state that as the script writing team, we did not set out to “demonise ADHD medications,” rather than highlight the debate surrounding ADHD management approaches. We wanted to draw attention to the importance of having a systematic approach to drug prescribing in ADHD appreciating the benefits of medications as well as acknowledging their possible side effects. The storyline did encourage the exploration of other psycho-behavioural options before resorting to chemical interventions, but not the boycotting of ADHD medications or any medications for other psychiatric disorders for that matter. In a broad sense we wanted to promote the mindful use of drugs after careful assessment from a trained professional who is responsible enough to prescribe medications only when needed, rather than go for a quick fix.

The argument for a holistic approach to understand psychiatric conditions is an important agenda for El Shimi:

Our professional role dictates that we should engage with patients, their families and the public in all controversies surrounding mental health and wellbeing. Often, we do accept some medical facts as “gospel” without being aware that what we professionals consider as irrefutable is quite debatable and controversial in the medical world itself. In that sense it was especially important to find simple ways within the story dramatic arc to give voice to arguments and controversy. For example, I have specific views about the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification. The alternative “mental health concerns” approach argues that we abandon diagnosis of psychiatric disorders and that we should only treat symptoms. We know that there is huge variability between one patient’s presentation and another with the same disorder. The story of Paula Caplan is an example of controversy in psychiatry. In the early nineties, Paula was the only woman in the DSM committee who challenged the committee’s decisions about diagnostic criteria and accused them of being misogynist and racist. She eventually left the committee and wrote her book, They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.” Another example is seen in 2017 in Bessel Van der Kolk’s proposition for a new disorder called “Developmental Trauma Disorder” that clearly distinguishes between trauma in adulthood and trauma in childhood. Van der Kolk’s theory states that trauma in childhood has persistent long-term effects, and that PTSD as the only trauma-related diagnoses is not enough to characterise the spectrum of trauma-related disorders. His proposition was supported by various research evidence cited in his book “The body keeps the score.”2

El Shimi’s knowledge and beliefs around ADHD were inspired by learning from Greg Crosby, an international trainer for mental health therapists. She explains that he “argues that ADHD is not a ‘deficit’ in attention but rather a variability between very low focus to hyper-focus states depending on the dopamine levels in the brain. In a sense, while most brains can have a moderate level of dopamine available to perform tasks that are not interesting to them, the ADHD brain shifts from being ‘completely off’ when performing low interest tasks, to being ‘extremely on’ when performing high interest tasks, hence the term ‘variability’ rather than ‘deficit.’ This change was also suggested to the DSM committee but not (yet) approved.”

Commenting on the reaction to the presentation and management of ADHD in the series, Mona adds: “The response to the series from professionals and public opinion far exceeded our expectations. We started reading alternative diagnoses and analysis of the series characters from the viewers expressed on social media platforms. Some of those interpretations were conflicting or confusing. Our social media officer, Duaa Mohamed, thought it was crucial that we share our references, intentions, and background knowledge with the audience to resolve the confusion and provide the necessary psychoeducation.”

Take care of Zizi is adept in its portrayal of doctors as vulnerable human beings dealing with their own traumas; Dr. Samy and his son’s suicide is an intriguing storyline. Mona notes that this decision was intentional and part of their creative process:

Mariam Naoum, the script team leader, was keen on making all characters human and relatable. It was her suggestion that we show the healer’s healer, which was Dr. Shendy, the psychiatry consultant who was caring for Dr. Samy’s wellbeing in a professional capacity. At the end of the day a psychiatrist or a psychotherapist is a human being. Their life experience and personal views do affect their scientific opinions and treatment approaches. A therapist cannot remain neutral while dealing with their patients, they do get affected and triggered in treatment sessions, and then go on to process those emotions in a controlled professional environment with a supervisor colleague.

Finally, Mona champions a wider community involvement and engagement in mental health matters: “Accurate information about mental health is not widely known or easily accessible to the public but tends to be rather limited to practitioners and academics. People expect the right answers from ‘experts’ and in the process idealize those experts. In Zizi, we wanted to deconstruct mainstream concepts about mental health clients and practitioners, humanizing both. We wanted the public to ask questions and by doing so become proactive agents in maintaining their own mental health. Only then, can they accept and understand themselves and others beyond labels and categories.”