American journal of Orthopsychiatry, 70(2), April 2000 © 2000 American Orthopsychiatric Association, Inc.

Cultural Determinants in the Treatment of Arab Americans: A Primer for Mainstream Therapists Anna Y. Nobles, M.Ed., and Daniel T. Sciarra, Ph.D. As the population of Arab Americans grows, so does their presence among mental health clientele, creating a need among clinicians for information about these clients. The broad lines of Arab culture are delineated: its roots, language, religion, and political history; patterns of immigration to the United States; and the salient differences between Arab culture and the dominant U.S. culture. The effects of negative stereotyping and discrimination against Arab Americans are examined, as are specific clinical issues in treating them. Recommendations for more culturally sensitive treatment are enumerated.

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n the United States, 50% of minority group members, compared to 30% of whites, terminate counseling after the first session (Sue & Sue, 1990). The difference is significant and due in part to minority clients' negative experiences stemming from counselors' lack of sensitivity to the client's culture (Fukuyama, 1990; Gladding, 1992). However, with a burgeoning of multiculturalism— referred to as the "fourth force in counseling" (Pederson, 1991)—awareness, knowledge, and skills are now acknowledged as the three broad areas in which competence is needed for working effectively across cultures (Sue et al, 1982; Sue, Arredondo, & McDavis, 1995). The number of Arab Americans, currently estimated at three million (Abudabbeh, 1996), is steadily increasing. Their cultural background, however, is little understood and, because of hostile relations between the U.S. and some Arab countries, there is considerable prejudice against Arab Americans. Thus, they often find it difficult to secure mental health services that are sensitive to their cultural background. ARAB CULTURE

The Arab world consists of 21 countries divided geographically into two major parts, one in South-

west Asia, the other in North Africa. These nations cover considerable territory and vary in size and population. Furthermore, they are politically diverse, including monarchies, military governments, and socialist republics (Nydell, 1987). Such heterogeneity might seem to preclude such a thing as an Arab culture. However, Arab regimes that arose after the partition of Palestine and the creation of the state of Israel (e.g., Syria. Egypt, and Jordan, which were defeated in the 1967 Arab-Israeli war) are committed to nationalism and the union of Arab nations (Abudabbeh, 1996). These regimes do not see themselves as separate nations inhabiting separate political entities. In their view, all Arabs constitute one nation, the boundaries dividing them are temporary, and sooner or later they will be united (Patai, 1973; Mansfield, 1992). A general description of any cultural group runs the risk of engendering stereotypes and overlooking intragroup differences. The following delineation is meant to be representative of the broad lines of Arab culture, which will not be reflected in every Arab, nor in all to the same degree. A good rule of thumb for mainstream therapists is to question the extent to which a particular client conforms to and differs from what the therapist knows about his or her cultural background (Gushue & Sciarra, 1995).

Based on a paper presented at the 1997 annual meeting of the American Psychological Association, in Chicago. Authors are at: University of Tennessee, Chattanooga (Nobles); and Hofstra University, Hempstead, N.Y. (Sciarra).

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Nobles & Sciarra Cultural Roots In pre-Biblical and Biblical times, Arabs were a nomadic people inhabiting the Arabian Peninsula. With the rise of Islam in the seventh century A.D. and its expansion over parts of Asia, Africa, and Europe, Arabic culture and language spread. As millions in the Middle East and North Africa adopted the Arabic language and integrated Arabic culture with that of their own, Arab identity lost its purely ethnic roots. Thus, the word Arab today is a cultural, linguistic, and to some extent political term, since it refers to all the countries that were Arabized through conquest by the Muslim Arabs. Arabization was accomplished by intermarriage, conversion to Islam, or adoption of the Arabic language (Abraham, 1995). As a result, some populations (e.g., the Christian communities of Copts in Egypt and Maronites in Lebanon) are Arabs by speech, not by race or religion (Atiyah, 1958). Political History The seventh and eighth centuries marked the peak of the Arab empire. Arabs tend to look back on it as a glorious and ideal period, when political harmony was the norm in the expansion effort (Hottinger, 1963; Mansfield, 1992). The 13th century saw Europe prosper and the Arab empire begin to decline as they were invaded by Mongols, then Crusaders, and finally Turks, who established more than 100 years of hegemony in the Arab world (Isenberg, 1976). Division of the Arab world continued during World War I, as the Allied forces occupied the entire North African Coast. The 1917 agreement (the Balfour Declaration) between the British and the Jews to make Palestine the latter's homeland came as a blow to Arabs in general and to Palestinian Arabs in particular, perceiving their homeland occupied by outsiders. The impact of this history of decline on Arab ideas and feelings cannot be overemphasized. Many Arabs deeply resented the domination of Europeans, which saw the imposition of foreign languages and culture, and the insinuation of the U.S. into the Arab-Israeli conflict; they felt that history had betrayed them (Mansfield, 1992), and the psychological wounds are still open. Some Arab thinkers tend to hold European colonialism responsible for Arab poverty, psychological conflicts, and, most of all, the "bloody tragedy" of Palestine (Patai, 1973). As Isenberg (1976) noted, these experiences have left a negative impression of the West on

183 Arabs, many of whom believe that the West is capable of taking away their moral values and family ties in the same manner that it once took their freedom. Since the mid-1970s, the return to Islamic fundamentalism has spread throughout the Islamic East, popularized as an antidote to Western domination and influence (El Guindi, 1995). Religion Though not all Arabs are Muslim,* or Muslims Arab, it is hard to overestimate the influence of Islam on the Arab world, in which religion regulates everyday behavior through positive and negative commandments that are carefully observed (Patai, 1973). Religion is not just one aspect of life but its center, effecting all activity, thought, and feeling. The practice of Islam (which means "submission to God") ideally results in a psychological certainty of inward protection from serious harm, allowing the believer a high level of tolerance and dignity (Patai, 1973). Equally important is the belief in fatalism: Neither the individual himself nor external factors can change a man's God-given character, which remains with him throughout his life and which destines him to a certain way of life. (p. 148)

Since deeds and behavior are predetermined, individuals have no choice and consequently cannot be held morally responsible for what they do. Furthermore, long-term planning is considered sinful, since it indicates a lack of trust in divine providence (Patai, 1973). Nydell (1987) summarized the basic Arab religious attitudes as follows: 1) Everyone believes in God, acknowledges God's powers, and has a religious affiliation. 2) Humans cannot control all events; some things depend on God (i.e., "fate"). 3) Piety is one of the most admirable characteristics in a person. 4) There should be no separation between church and state; religion should be taught in schools and promoted by governments. 5) Religious tenets should not be subjected to "liberal" interpretations or modifications, which can threaten established beliefs and practices. Language Arabic is the native and official language of all the Arab countries. In 1973, it became the sixth •For example, Iran was part of the Arab Empire during the spread of Islam and remains Muslim to this day; however, it never became Arabized. On the other hand, Christians in Lebanon, Syria, Iraq, and Palestine are direct descendants of early Arabs.

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official language of the United nations and the fourth most widely spoken in the world (Nydell, 1987). Approximately 130 million people speak Arabic (Abudabbeh, 1996), which is also the language of the Koran. According to Savory (1976): ...the most important formative factor creating the Arab consciousness is the Arabic language, which is the bearer of their culture, the vehicle of their history and the sacred tongue of the religion of the majority, (p.147)

The Arabic language is complex. Spoken dialects (colloquial Arabic) can be as different as Spanish and Italian. They are all different from classical Arabic, which is spoken by educated Arabs and, as the written version of the language, is substantially the same throughout the Arab world. Patai (1973) has suggested that the existence of colloquial varieties causes psychological problems. A good command of classical Arabic is highly admired (Abudabbeh, 1996) and considered a function of the higher, idealized self (Mansfield, 1992); since less educated Arabs are unable to speak it, they may feel inferior to those who do . In Arabic, the way something is said is just as important as its content. Nydell (1987) pointed out that Arabs use many repetitions of phrases and themes, along with exaggerated reports and descriptions, to stress the importance of what is being said. In times of anger, they may threaten, make promises, or use nationalistic slogans, but these are not intended to be taken literally. This is a creative and metaphorical use of language, a form of fantasy for sake of emotional satisfaction and expression of feeling. Arab thinking tends to extremes, with little capacity for accepting the grey areas of reality. Arabs tend to use descriptors such as "excellent," "magnificent," "great," "terrible," "disgusting," and "stupid," and very seldom use qualifiers. Patai (1973) referred to the many Arab scientists who hold that such extremes are partly the result of the desert climate, noted for its own extremes of daytime heat, night-time cold, dry summers, and bitter winters. Arabs also use many euphemisms for uncomfortable situations such as death, illness, or disaster (Nydell, 1987). For example, instead of saying someone is sick, an Arab may say she or he is a little tired.

since some Arabs, suspicious of government authorities, conceal their ethnic affiliation. In any case, the number of Arab immigrants to North America is growing with continuing political instability in the Arab world (El-Badry, 1994), and unofficial estimates place the number of ArabAmericans at closer to three million. Immigration Patterns

Historically, Arab Americans arrived in the U.S. in three different major waves, each under special circumstances that affected the acculturative process (Barazangi, 1989). First wave. Occurring in the late 19th century, the first wave of Arab immigration was comprised primarily of Arab Christians from Syria and Lebanon (Abraham, 1995). They were predominantly males who had left their families behind, intending to stay in the U.S. only until they had earned sufficient money to improve their lives back home (Abu-Laban & Suleiman, 1989). From this early wave emerged a group of poets, artists, and writers (e.g., Kahil Gibran), who became permanent residents of the U.S., settling in such major urban centers as New York and Boston (Abraham, 1995). Second wave. The second wave of immigration took place about the middle of the 20th century, and included many more Muslims than did the first (El-Badry, 1994). Many of them were Palestinians displaced after the establishment of Israel in 1948. Also included in this wave were Iraqis and Syrians who were escaping political conflict in their countries of origin. Third wave. Starting in the mid-1960s, and continuing to the present, the third wave includes many professionals and entrepreneurs fleeing political unrest and wars (Abraham, 1989) who would otherwise have remained in their country of origin (El-Badry, 1994). This group is more educated, young, and affluent than the average Arab, and most have become U.S. citizens. They held executive positions in their homelands and, in bringing their entrepreneurial skills to the U.S., have proved attractive to the corporate world (El-Badry, 1994). Stereotypes

ARAB AMERICANS

Abraham (1995) felt that the 1990 census estimate of 870,000 Arab Americans living in the U.S. (U.S. Bureau of the Census, 1990) is inaccurate,

During eight years of television viewing (starting in 1975), Shaheen (1984) documented over a hundred popular entertainment programs, cartoons, and major documentaries telecast on net-

Nobles & Sciarra work, independent, and public channels, and totaling nearly two hundred episodes, that related to Arabs. He found that all channels portrayed Arabs as billionaires, bombers, belly dancers, or unfriendly desert dwellers with veiled harems. Discussing the reinforcement of Arab stereotypes by American television, films, and other media, Shaheen (1997) pointed out that in reality only 2% of the present-day Arab population lives a nomadic or harem life, and that these were never among the prevailing customs of most Arab countries. While some of the stereotypes depicted by Shaheen (1984) have since lost their appeal, one that has endured is that of rebel and terrorist bomber (Said, 1979). This is partly due to media coverage of sensational bombings, especially of Israelis by Palestinians, which has left the impression that all Arabs are political radicals. The recent U.S. military strikes against Osama bin Laden have contributed to this stereotype. Shaheen (1984) wrote: Stereotyping of Arabs is just as wrong as assuming that Blacks are lazy, Hispanics are dirty, Jews are greedy and Italians are criminals...Like every national or ethnic group, Arabs are made up of good decent people with the usual mix of one percenters, the bad apples found in any barrel, (p. 25)

Second-Culture Acquisition Arab Americans take pride in their cultural heritage and its many contributions to philosophy, literature, medicine, architecture, art, mathematics, and the natural sciences. At the same time, they feel misunderstood and wrongly characterized by most Westerners (Nydell, 1987): defamed in the news media, Hollywood productions, and political speeches. Barazangi (1989) pointed out that the stereotyping of the Arab-American community in the U.S. has made its members feel like sojourners, very different from the mainstream culture. As a result, many have experienced, and are still experiencing, marginalization, which has led to ways of coping that can be divided into three major types. Denial of ethnic identity. Arab Americans from all groups—recent immigrants, assimilated immigrants, or native born—may choose to deny their ethnic background (Abraham, 1995). Abu-Laban and Suleiman (1989) pointed out that some Arabs never reveal their ethnic background because of stereotyping. They give as an example the consumer advocate, Ralph Nader, who has seldom (if ever) referred to his Arab lineage. Such denial was particularly true of first-wave immigrants who, since they were mostly Christian and isolated from

185 their homeland, tended to marry and assimilate more readily into the dominant culture. Withdrawal. Most of the Arab Americans who have chosen to withdraw from American society are third-wave immigrants, including recent arrivals (Abu-Laban, 1989). Unlike earlier immigrants, these Arab Americans co-exist in two social, psychological, and physical worlds. They are able to stay in touch with their country of origin through advances in telecommunications; this reinforces their sense of Arab community and tradition, intensifying a preference for living in ethnic Arab neighborhoods or near other Arab Americans in the suburbs. Finding their ethnic identity and religious traditions alien to the dominant American culture, they prefer to stay withdrawn in order to prevent assimilation (Abraham, 1995). Engaging mainstream society. Arab Americans who engage with the dominant culture tend to have distant ancestral ties, be successful, have high leadership positions, advocate secularism, or identify with Christianity. Concerned with acceptance into the dominant society, they emphasize the commonalities between Arab and American cultures, or between Islam and Christianity (Abraham, 1995). They identify themselves as Americans who happen to be of Arab ancestry. Cultural Differences While intragroup differences exist among Arab Americans in terms of second-culture acquisition and cultural identity, some of the differences between the values and traditions of Arab culture and those of the dominant culture of the United States are noteworthy. Family As Nydell (1987) explained, Arab society is built around the extended family system, creating a strong bond among blood relatives. Family is the first priority, exceeding obligations to work—an attitude understood by Arab employers, who will excuse an employee's absence or tardiness if family obligations or duties are involved. Budman, Lipson, and Meleis (1992) wrote: Arabs do not see themselves primarily as individuals but rather as members of groups, especially family groups, (p. 360)

Family members support each other both emotionally and financially (Nydell, 1987). Arabs consider family the place of refuge that provides them with security and reassurance in an unpredictable

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world. The reputation of a family member reflects upon the entire family: One's family name is a ready-made identification which reveals to all both one's reputation and one's access to assistance. (El Saadawi, 1993, p. 14)

Irresponsible behavior that is apt to destroy the perpetrator is also apt to destroy the entire family. The importance of family can give power and control over its individual members, who may be pressured to abide by acceptable behavior patterns at the cost of development of their own personality. Parents seldom encourage independence and like to remain involved in their children's lives for as long as possible. It is not uncommon for Arab parents to make such major decisions for their children as to choice of a career or marital partner, (Budman el al., 1992, p. 361)

Well-defined cultural norms dictate that the oldest son be trained at an early age to become head of the extended family. He [the eldest son] is given every privilege, according to the means of the family, with the expectation that, as an adult, he will care for his aging parents and younger siblings, especially any unmarried sisters. (Najjar, 1994, p. 41)

The significant role of the eldest son begins at birth, when his father and mother become known by his name (El Saadawi, 1993); for example, if the oldest son's name is Sammi, his parents will be called "Um Sammi" and "Abu Saammi" ("mother/father of Sammi"). Socioeconomic Status

An Arab family's social, economic, or political status determines its role as an instrument of control (Tucker, 1993). For instance, a wealthy family functions as an extended unit whose main concern is to maintain its economic status. Although arranged marriages (in which parents choose suitable mates for their children) are no longer practiced in the same manner as in ancient days, preferred marriages among the wealthy, even today, are to first or second cousins (Nydell, 1987), a pattern ensuring that its wealth and inheritance remain within the family. On the other hand, lowerclass families are much less concerned about care ful marriage choices (Tucker, 1993). Barakat (1985) reported that field studies conducted in diverse Arab communities indicated an overall rate of only 3%-8% for endogamous marriages but a significantly higher rate for such marriages in traditional and isolated communities.

Arab culture places certain limitations on the activities of the wealthy in order to maintain their status and a good public image. For example, the upper-class person will refuse to engage in any kind of manual labor, even washing the car or sweeping the sidewalk. Physical appearance is important; proper clothing (even traditional Islamic dress) reflects social standing, as well as wealth (which is why Arabs are often surprised to see rich and educated foreigners wearing old clothes and faded jeans, which they associate with being poor and lower class). It is worth noting that Arab Muslim families are more intensely affected by cultural traditions, which are linked to Islamic teachings, than are Arab Christian families. Child-Rearing Practices

Most Arab children grow up among numerous loving and nurturing caregivers, not only their parents but extended family members, who share caretaking responsibilities (Nydell, 1987). The presence of numerous authority figures appears to be universal in Arab culture. The traditional preference for male over female offspring stems from the general belief that men contribute more to their families' influence and effectiveness. This is beginning to change in the Arab community at large, but is still evident in some traditional families. Among Arab children, the attachment to the mother is usually affectionate, while that to the father is based more on respect and fear, largely because of the different treatment received from each parent (Patai, 1973; Abudabbeh, 1996). Stereotypically, the father is the stern, authoritarian figure, while the mother is loving and compassionate. According to Nydell (1987), Arabs tend to administer more corporal punishment than do Westerners. Children are expected and taught to behave in a certain way in order to maintain an acceptable social image. They are not conditioned to judge or criticize their own behavior in terms of right or wrong, which would give rise to guilt for bad behavior, but in terms of acceptability, which gives rise to shame for behavior that does not meet social expectations. Consequently, children are more concerned with how other people see them than with how they see themselves, and there is great social pressure to conform. The strong religious context of Arab culture intensifies such conformity and establishes in the child's mind a close association between sin and nonconformity.

Nobles & Sciarra Sexuality The realm of sex and sexual relationships is a much more personal and sensitive area of life for Arabs than for Westerners (Patai, 1973), resulting in a paucity of writing about Arab sexual mores (Mansfield, 1992). Timini (1995) indicated that Muslim Arabs generally have a positive view of sexuality, believing that sexual union within marriage is the highest good in the eyes of God. For Arabs in general, social and religious values determine when sex is good and when it is bad. As Davis and Davis (1993) have emphasized, Arab cultural ideals and reality are often contradictory. For example, the restrictions placed on women are not shared by men, so that a single man can experiment sexually with women but will only marry a virgin. Moreover, a woman who commits any sexual offense loses her honor forever and destroys not only her own but her family's reputation, since it is held accountable for her actions by the local community. As a rule, Arab women, are expected to prove their virginity on their wedding night. Najjar (1994) wrote of the cultural differences regarding women: I know that the women's movement in this country [United States] has yet a long way to go, but compared to the restrictions on women my society has, this culture is liberating, (p. 41)

Najjar was a university student in the U.S. when she started to struggle with issues of dating and sexual intimacy. Although she was 24 years old, and free to do as she pleased, her ingrained perceptions of what was proper behavior continued to restrict her. The emancipation of women in Arab culture continues to be a vibrant and complex process. For instance, even though they had been influenced by Western ideas under the leadership of the Shah, millions of Iranian women supported (apparently with no coercion from their husbands) a return to Islamic fundamentalism and the more traditional role of women under Ayotollah Khomeini. Social change in many Arab countries can be reduced to the role of women in society (Mansfield, 1992). Throughout the 20th century, the status of women in the Arab world has fluctuated as a result of conflicts between reformists, who reinterpret the Koran on the basis of reason, and militant scripturalists, who adhere fundamentally and even violently to those texts that favor men over women (Altorki, 1995). Thus, the current status of women in a par-

187 ticular Arab country can be a good indicator of which group, reformist or spiritualist, is now dominant. Hospitality Arabs are famous for their hospitality. Kanafani (1993) traced the origin of this tradition to the Bedouins, who saw a need to protect travelers who were passing through their hostile desert. In Nydell's (1987) words, Social formalities and rules of etiquette are extremely important in Arab society. Good manners constitute one of the more salient factors in evaluating a person's character, (p. 57)

Because people are judged by how they receive and treat their guests, hospitality is the most frequently used measure for increasing one's selfrespect (Patai, 1973). For Arabs, hospitality and generosity are so closely related as to have the same meaning (Nydell, 1987). For instance, guests never leave a home, shop, or business without being offered something to drink; whereas Westerners might ask guests if they would like something to drink, Arabs would ask whether they preferred coffee or tea. Or, if two friends meet on a bus, each will insist on paying the other's fare until one gives way and accepts the offer. Arab culture insists that a guest is always welcome, whatever the inconvenience—the only exception being when a woman is at home alone and a man calls unexpectedly. Arabs enjoy inviting guests to their homes for meals, at which their ultimate form of generosity is exhibited in the serving of great quantities of food and varieties of dishes. Expression of Feelings Certain cultural beliefs have endured over sufficient time to have become central to the development of what might be called the Arab personality. First, while they subscribe to the law and historical events, Arabs are more concerned about people and their feelings. They may be more subjective in their approach to certain situations than are Westerners, who are taught to attempt objectivity and try to prevent emotion from interfering with their behavior. On the other hand, Arabs (even men) express their emotions freely, talking openly about pain and sorrow, and weeping, even lamenting, when death occurs. Such behavior can shock Westerners, who may see it as a loss of control. Nydell (1987) concluded that Arab beliefs are centered around the assumptions that:

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...everyone loves children, wisdom increases with age, and the inherent personalities of men and women are vastly different. (p. 15)

IMPLICATIONS FOR TREATMENT Like many nondominant groups that struggle with issues of second-culture acquisition, Arab Americans are at risk of developing problems associated with emotional well-being and psychological health. Their acculturative stress is exacerbated by the discrimination and prejudice they commonly face upon arrival in the U.S. (Pollara & Meleis, 1995). Second-Culture Acquisition Acquiring a second culture can create great ambivalence in Arab Americans as they strive to maintain their cultural roots, of which they are proud, while trying to become familiar with and integrated into American culture (Meleis, 1991). The result can be a feeling that they belong to neither culture. In their homes, Arab Americans may speak the colloquial Arabic of their origin and exhibit the authoritarian attitudes normal in traditional Arab society, while at work they speak English and behave like Americans. The result may be a psychological struggle among different attitudes, thought processes, and behavioral patterns (Patai, 1973). Unable to identify emotionally with either culture, Arab Americans can find themselves clinging to the traditional Arab culture even though they feel that modernization is desirable. This conflict can pull them apart, and the task of therapy is to help integrate the conflicting forces into a new and more fruitful cultural configuration and bicultural identity. Family Issues Arab-American parents struggle continuously for balance in helping their children maintain their ethnic identity while acquiring entrance into the larger culture. Pollara and Meleis (1995), in a study of 30 Christian Jordanian mothers of adolescents in the Los Angeles area, found that their greatest source of stress was in the attempt to raise their children within a different cultural context. The mothers reported intense and persistent worry, despair, guilt, confusion, and fear of losing respect and control over parenting. Their feelings were intensified by the perception that people in their new environment did not understand the depth of their concerns and the extent of their fears.

Adolescent identity. Adolescence in Arab countries tends to be early, brief, and less stormy than in the West. While Western adolescents develop their individual identities by separating from their families and forming strong peer relationships, Arab culture demands that adolescents shape themselves to fit their family environment (Pollara & Meleis, 1995). Arab-American parents do not expect their adolescent children to act out, become self-centered, or engage in nonconformist behavior. They consider adolescence a period of hormonal imbalance with mood changes evidenced by impatience, nervousness, frustration, low tolerance in the male, and a certain degree of withdrawal in the female (Budman et al, 1992). As a result, issues of identity and belonging can be somewhat traumatic for Arab-American adolescents. They experience negative discrimination from a dominant culture that has a different set of expectations for puberty, dating, marriage, and attitudes toward parents and elders than their own culture (Bowen & Early, 1993). They are caught between the two cultures—on the one hand seeking acceptance from their families, on the other hand tugged by peer pressure to seek acceptance in American society (Timini, 1995). This dilemma can result in either enmeshment or disengagement between adolescents and their parents. Fear of losing their adolescent to the new culture can make parents overprotective, preventing the child from developing his or her own identity (Jackson, 1991). Disengagement occurs when adolescents feel pressured to accept the family's values and life style but choose to reject their minority cultural background and adopt the dominant culture of their peers. Timini (1995) concluded that ArabAmerican adolescents were likely to develop guilt feelings if they abandoned their family's traditions and refused to abide by its rules. Clinical Intervention Clinicians providing mental health services to Arab Americans are likely to encounter certain expectations and types of behavior in their clients. Some awareness of the cultural factors already discussed, combined with the following observations, should help ensure a degree of cultural sensitivity in rendering the services. /. Because of their fatalistic attitudes, a high degree of resistance to cooperation should be expected from Arab-American clients, especially Muslims.

Nobles & Sciarra 2. Arab families seek mental health services only as a last resort, and are more likely to telephone for help than come in person for treatment (Abudabbeh, 1996). 3. Be aware of the impact of negative stereotyping and discrimination on Arab Americans. 4. While Arabs tend to be highly emotional and full of zest for life, they are also bounded by stringent rules and expectations. 5. In the Arab culture, the behavior of an individual reflects on the entire family. Clients' immediate issues, therefore, are likely to be accompanied by such factors as guilt, shame, dependence, and low self-esteem. 6. The themes of honor and shame are the main components of everyday life in Arab society. 7. Arab families encourage their members to remain dependent, discouraging self-reliance and differentiation. 8. Social hierarchies in the Arab culture influence individual behavior; e.g., men from different social classes would be embarrassed if they found themselves invited to the same event. 9. Discussion of matters related to illness, death, or other painful events is uncomfortable for Arab clients. It is advisable to avoid direct reference to them, since it can worsen a bad situation or cause such intense hurt and resentment that the client may terminate therapy. 10. Arabs are brought up to view disadvantages (physical, economic, etc.) and relational problems as shameful and might resist admitting to them. 11. Therapists should be careful about disclosure of personal information, since negative data about family life or relationships may adversely affect their image and status in an Arab client's eyes. On the other hand, positive information (e.g., successful events or connection to famous persons) can induce admiration. 12. Be hospitable; an Arab client who is not invited to participate when the therapist in eating or drinking is likely to be offended. 13. In general, Arabs stand and sit closer to each other than is the norm for Westerners. The space that Westerners assume for intimate conversations, would be considered comfortable for ordinary conversations by Arabs. Individuals of the same gender touch each other repeatedly during a conversation; e.g., it is common to see two women or two men holding hands—this is a sign of friendship—and kissing on both cheeks is customary in greeting someone of the same sex.

189 14. In conversation, Arabs are accustomed to repetitions of the same idea or issue for purpose of emphasis. Repeated responses are therefore needed for reassurance: if a statement is made softly and not repeated, an Arab may wonder if the speaker really means what he or she is saying. This originates in the Arabic language, which uses many different phrases with the same meaning. Therapists should not be surprised if a client keeps asking for reassurance by asking "really?" 15. Family intimacy is achieved indirectly in Arab society; family members rely more on unspoken expectations than on overt verbalization and are not accustomed to confronting each other. Although family therapy is recommended as a modality for treating Arab Americans, because of Arab family structure, asking family members to address each other in therapy is likely to cause frustration and resistance. 16. The transition of an Arab immigrant family from an extended family support system to a sudden nuclear family situation can give rise to feelings of isolation, disengagement, and enmeshment. The trained clinician should be able to explore these issues and respond to the often desperate need for support. 17. Believing that dressing well is essential to self-respect, Arab clients are reassured by a presentable appearance (including no long hair for men or revealing clothes for women). 18. Be considerate of Arab etiquette. In terms of nonverbal behavior, this includes not sitting so that the soles of one's shoes face the other person (an insult); not standing carelessly, e.g., leaning against the wall or keeping hands in pockets (lack of respect); and not failing to shake hands when clients arrive and depart (very rude and cold). 19. An Arab-American client family is likely to become attached and consider the therapist a member of the family, which might give rise to an invitation to their home. However, a polite refusal is usually accepted. 20. Be sensitive to any characteristics of the dominant culture that an Arab client may be acquiring, which will be affected by such variables as client's socioeconomic status, age, gender, religious affiliation, and language. Nominal membership in a cultural group does not necessarily indicate possession of all that group's characteristics. 21. Termination can be stressful and traumatic for Arab clients if not handled with great care. The family will not expect the relationship to end;

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Cultural Determinants in Treatment of Arab Americans

therefore, therapists should refer to termination as temporary, indicating that the family should feel free to contact them any time a difficult situation arises. Otherwise, client and family may consider the therapist untrustworthy, cold, and inconsiderate. CONCLUSION While it has only scratched the surface, this article has attempted to open up some of the issues that the mental health community must face in providing culturally sensitive services to Arab Americans. Their political history, strong religious background, and significant differences with the dominant culture of the United States complicate issues of second culture acquisition for Arab Americans. Furthermore, little is known about this population's use of mental health services. More research is needed to determine the extent and effectiveness of that use, as well as Arab Americans' perceptions of mental health treatment. At present, the mental health literature in English that might further the understanding of practitioners about Arab-American clients is sparse. Nevertheless, it is essential that those who work with this clientele become as knowledgeable as possible about its culture. Equally necessary is a sensitivity to that culture and to the issues with which its members must cope in living in a dominant culture of which some mores are radically different from their own. In therapeutic work with Arab-American clients, therapists must bring to bear all the information and awareness at their disposal, while keeping in mind that the encounter is also a potential source of enrichment for both client and therapist. Such considerations might go far to ameliorate any tendency to regard the dominant culture as the norm to which clients of any nondominant culture should aspire. Therapists must take care to give this kind of cultural imperialism a wide berth because it silences the discourse of the nondominant culture and imposes that of the dominant culture. The rise in the population of Arab Americans in the United States offers the mental health community yet another opportunity to transcend its frequent role as the handmaiden of the status quo and reach out to those maligned by discrimination, bigotry, and racism. References Abraham, N. (1989). Arab-American marginality: Mythos and praxis. In B. Abu-Laban & M.W. Suleiman (Eds.), Arab

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