Sensitive Social Work Practice with Arab Clients in Mental Health
by: Alean Al-Krenawi and
John R. Graham
Several culturally specific practical considerations should
inform social work interventions with ethnic Arab peoples in Arab countries
or in Western nations. These include taking into account gender relations,
individuals' places in their families and communities, patterns of mental
health services use, and, for practice in Western nations, the client's level
of acculturation. Such aspects provide the basis for specific guidelines
in working with ethnic Arab mental health clients. These include an emphasis
on short-term, directive treatment; communication patterns that are passive
and informal; patients' understanding of external loci of control and their
use of ethnospecific idioms of distress; and, where appropriate, the integration
of modern and traditional healing systems.
Key words: Arab ethnic origin; cross-cultural
studies; ethnic minority groups; mental health care practice
Ethnic Arab peoples have one of the world's highest rates
of population increase. There are 255 million people in 21 Arab countries
in North Africa and the Middle East, and they constitute a significant and
population in such Western countries as Australia (210,000), Canada (80,000),
France (2 million), Britain (210,000), and the United States (700,000),
as well as Israel (1 million). (Al-Boustani & Farques, 1991; Al-Krenawi & Graham,
1998; UNESCO, 1996). A notable proportion of Arab peoples are Muslim, and
Islam is the world's second most practiced religion, with one of the highest
increases in the number of practitioners. Today there are an estimated 6 million
Muslims in the United States, and nearly 15 percent are people of Arab ethnic
origin (Newsweek, 1998). Despite Arab peoples' presence in the West
and East, there has been little published social work practice research to
date related to this population.
Researchers in social work (Al-Krenawi & Graham, 1996a,
1996b, 1997a, 1997b; Al-Krenawi, Graham, & Al-Krenawi, 1997; Lum, 1992;
Mass & Al-Krenawi, 1994) and allied disciplines (Al-Issa, 1995; Bilu & Witztum,
1995; Budman, Lipson, & Meleis, 1992) have differentiated among the knowledge
and skills necessary to respond to the ethnic and racial diversity of people
who may need mental health and social services. The literature provides insight
into mental health practice with families of various ethnic origins, among
them African (Franklin, Sarr, Gueye, & Sylla, 1996), African American (Ahia,
1997; Baker, 1994; Kendall, 1996; Logan, 1996), Asian American (Lorenzo, 1988),
Chinese (Bentelspacher, DeSilva, Goh, & LaRowe, 1996; Lai, 1995; Pearson,
1996; Pearson & Phillips, 1994; Shek, 1996; Wang, 1994; Xiong et al., 1994),
Greek (Madianos, Gefou-Madianou, & Costas, 1993), Italian (Fandetti & Gelfand,
1978), Japanese American (Hsu, Tseng, Ashton, & McDermott, 1983), Korean
(Hurh & Kim, 1994), ), Latino (De Snyder, Diaz-Perez, Maldonado, & Bautista,
1998), Maori (Chaplow, Chaplow, & Maniapoto, 1993), Native American
(Angell, 1997; Trimble, 1990), and Vietnamese (Phan, 1997). However, a
remains unknown, because multicultural social work is a heterogeneous and
phenomenon. Also, many ethnic groups, such as Arab peoples, have not received
comparable scrutiny by academic researchers.
Because the topic of social work practice with Arab peoples
is complex and because the literature disparate, the present article concentrates
on one field of intervention, mental health practice. Future research should
analyze other fieLDF such as addictions, child welfare, or gerontology.
Presented here is an overview of major practice intervention guidelines resulting
the integration of recent interdisciplinary research (Abudabbeh & Nydell,
1993; Al-Krenawi, 1996; Al-Krenawi & Graham, 1997b, 1997c; Al-Krenawi et
al., 1997; Jackson, 1997; Katchadourian, 1974; Qouta, Punamaki, & El-Sarraj,
1995; Savaya & Malkinson, 1997; Timmi, 1995). Although we recognize
the diverse aspects of ethnic Arab life, as well as its presence in virtually
all countries, the article emphasizes principles of mental health practice
have common and transnational applications. Similarly, the analysis applies
to Arab mental health clients of major faith traditions (Christian, Druze,
or Islam) living in rural or urban regions, whose communities are immersed in
the broadest spectrum of traditional to modern norms and values. Given this
journal's readership, particular emphasis is placed on ethnic Arab life in
North America, Europe, and other countries with Western-derived cultures (Budman
et al., 1992).
The article begins by introducing major aspects of ethnic
Arab societies and major processes of acculturation experienced in the West.
It then considers several culturally specific practical considerations that
should inform social work interventions. These include taking into account
gender relations, the individual's place within his or her family and community
and patterns of the use of mental health services.
The cultural facets in the context of life in Arab societies
were brought by immigrants who settled in Western nations, although rates of
acculturation considerably influence differential patterns of how Arab culture
is then transferred to and experienced in the new country. Ethnic Arab societies
are highly diverse and consist of heterogeneous systems of social differentiation
based on ethnic, linguistic, sectarian, familial, tribal, regional, socioeconomic,
and national identities. On one level, therefore, Arab peoples may be perceived
as having deep social and class distinctions and as being disunited and politically
fragmented, transnationally and within national borders. Ethnic Arab peoples
likewise follow more than one faith tradition. Also, Western cultural norms
have penetrated much of the Arab world, but their effect has been experienced
differently in communities and across societies.
At the same time Arab societies share many attributes, including
a common physical and geographic environment and a collective memory of
their place and role in history (Barakat, 1993). The Arab world is profoundly
balancing modern phenomena such as oil exploration with traditional structures
such as tribal castes. Its economic systems remain largely dependent and
underdeveloped, and, as one sociologist has remarked, "Its material and human resources
have been harnessed for the benefit of a small segment of the population and
on behalf of antagonistic external forces" (p. 26).
In the East and West, Arab societies are often complementary
patterns of family structures, patriarchy, primary group relations, spontaneity,
and expressiveness. They are also high context, emphasizing the collective
over the individual, having a slower pace of societal change, and a greater
sense of social stability (Al-Krenawi & Graham, 1996b, 1997a; Barakat,
1993; Hall, 1976). The family, therefore, is important to the homologous
interrelationship between the individual and group, as well as between
the individual's social
and economic status (Barakat). One of the most important parts of its kinship
structure is the hamula, which includes a number of generations in a
patrilineal line that have a common ancestor (Al-Haj, 1987; Al-Krenawi, 1998a).
In some ethnic Arab cultures, such as the Bedouin Arab in Egypt, Israel,
Jordan, Kuwait, Saudi Arabia, and Syria, several hamula together constitute
Family and Gender Constructions
Gender differences in Arab societies tend to remain strong,
and the social structure is male dominant. In Libyan society, women are
perceived as "physically and mentally weak in comparison to men" (Attir, 1985,
p. 121). Ethnic Arab women, particularly in Muslim society, have been viewed
as "powerless, subservient, and submissive" (Al-Haj, 1987, p. 103).
The male is the leader and highest authority in the household, the economy,
and the polity (Al-Krenawi, 1996; Morsy, 1993). In many Arab societies, women's
social status is strongly contingent on being married and rearing children,
especially boys (Al-Sadawi, 1977, 1995). Arranged marriages are frequent, and
women are expected to devote much of their time to caring for their families.
It is common for women not to have careers outside the home (Grossbard-Shechtman & Neuman,
1998). Many career women, even those attaining high degrees of success, defer
to spouses or families for major decisions (Hoodfar, 1997; Shalhoub-Kevorkian,
1997). Moreover, with Western media and cultural hegemony, Ahmad (cited in
Shalhoub-Kevorkian) contended that "the fear of losing an indigenous ďauthentic'
Islamic-Arab culture is used by society to control women further" (p.
Divorced women in Arab societies suffer emotionally and socially
(Tumush, 1989). A divorced woman's prospects for remarrying can be poor;
in many Muslim societies, they usually are restricted to becoming the second
of a married man or the wife of a widower or older man (Al-Krenawi & Graham,
1998; Brhoom, 1987; Hays & Zouari, 1995; Tumush). Mothers are known to
endure years of marital problems to avoid the stigma of divorce or the prospect
of losing their children (Al-Krenawi & Graham, 1998; Brhoom). This
possibility can be particularly severe in Muslim societies, because Islamic
hoLDF that fathers have custody over boys after the age of 7 and girls
age of 9 (Amar, 1984).
Individual Development in Arab Societies
Arab societies tend to be "father dominant" (patriarchal):
The father is the head of the family and is considered a powerful and charismatic
figure. He commands respect as the legitimate authority for all matters
of the family (El-Islam, 1983). The patriarchal structure extends throughout
all levels of society. The father of the nuclear family is subordinate to
father, who in turn defers to the authority of the head of the clan. All
clan heads are subordinate to the head of the tribe or hamula. The
tribal or clan leader also serves as the spiritual and practical father of
grouphe represents the collective to the outside world, oversees
the rules for the clan or tribe, and guides their actions. In effect, the
structure creates a complete and autonomous society within a society, functioning
as a single unit.
Regardless of whether ethnic Arabs constitute a minority or
majority in a particular society, the Arab school system throughout the
Middle East and north Africa is strongly representative of Arab culture (Chaleby,
1987b). In many Arab schools, the curriculum is based largely on rote learning
and on remembering facts, rather than on developing individual interpretations
and analysis. Conformity, rather than independent thought and creativity,
predominate (Chaleby; Geraisy, 1984). The teacher is a strong authority figure,
society's hierarchical, authoritarian nature, and its insistence on respecting
one's elders. Adults are perceived as the source of knowledge, wisdom,
authority (Barakat, 1993; Sharabi, 1975). From early childhood, the individual
learns that knowledge and wisdom are passed on by the old to the young
and not vice versa (El-Islam, 1989). This viewpoint is expressed in many fables
and in sayings such as "Wisdom is found among adults," or "Anyone
who is a day older than you in age is a year older than you in understanding."
Processes of Acculturation
As social scientists long ago concluded, immigrants invariably
experience processes of "adapting" and "adjusting" to life
in a new country (Eleftheriadou, 1997; Ng, 1998). Ethnic Arab immigrants to
Western countries are known to experience divided loyalties between the ways
of the new country and those of the old and the dilemma "of whether to
reject or embrace assimilation, secularism, and Western education" (Fares,
1991; Jabbra, 1991, p.43), among other phenomena. This dynamic, in turn, is
also influenced by ongoing debates in the new country, society wide, over assimilation
of ethnic minority cultures versus a more pluralist and multicultural approach.
Lambert and Taylor (1990) argued that in the United States in particular, a "fine
line" exists "between retaining one's ethnic identity and being considered" not
part of that country. Arab peoples, for their part, are thought to embrace
multiculturalism over assimilation with greater intensity than some other ethnic
minority cultures (Lambert & Taylor). Although one researcher went so far
as to describe some ethnic Arab communities in the West as "a nation in
exile rather than as immigrants" (Stockton, 1985, p. 123), it is probably
more accurate to emphasize the heterogeneity of acculturation within specific
Arab communities and among Arab peoples in general. Indeed, acculturation
may differ from one family member to another.
At the same time, nascent research provides provisional evidence
that some factors may be associated with Arab peoples' greater acculturation
to and life satisfaction in some Western countries. These factors include
longer residence in a host country, younger age at immigration, not recently
one's Arab country homeland, and being of a Christian religious background
(Faragallah, Schumm, & Webb, 1997). Thus, it is essential to emphasize
how various Arab cultural values may resonate differently to the Arab social
work client, depending in part on level of acculturation and those associative
variables just noted. As for family functioning, it is well known that periods
of disharmony are common on and after arrival in a new country and as familial
role patterns change (Eldering & Knorth, 1998a, 1998b). In some instances,
family satisfaction itself may be associated negatively with acculturation
(Faragallah et al.), and family conflicts among Arab social work clients may
center on schooling, children going out with friends, and arranged marriages
(Eldering & Knorth).
A limited range of findings suggests that in some Arab cultures,
males may be better acculturated than females, but for both sexes, acculturation
was positively related to better mental health (Ghaffarian, 1987). Research
in Belgium revealed that with increasing acculturation, the demand for
preventive care among clients of Arab origin decreased, delays for consulting
curative problem were reduced, and prognoses were improved. But vague complaints
are, as will be seen, consistent with Arab culture) increased (Van der
Stuyft, De Muynck, Schillemans, & Timmerman, 1989).
Guidelines for Mental Health Practice with Ethnic Arab Clients
Mental health practice with Arab peoples requires several
ethnospecific approaches, which are described below and supplemented with brief
Acculturation is a central component in conceiving social
work services in the West. In providing social work services to an ethnic Arab
family in the West, it is essential to consider the level of acculturation
and its differential effect on families. Before a treatment plan is formulated,
a detailed history should be taken. In the West this could include length of
time outside the country of origin and reasons for and conditions under which
emigration occurred. In the West or East, level of social and family support
available and degree of religious affiliation are important factors. There
is a significant difference, for example, between the ethnic Arab who is here
as a student and is struggling with issues of sexuality and a middle-aged man
who has left his homeland in turmoil and is suffering from a posttraumatic
stress disorder. Thus, an assessment of the client's personal background and
level of acculturation will alert the sensitive practitioner to potential cultural
conflicts with regard to treatment. It is also imperative clearly to identify
culturally appropriate interventions in light of acculturation and with reference
to facets discussed in the following guidelines.
Mental Health Services and Stigmatization
Mental health services can be stigmatizing, particularly for
women. Ethnic Arab clients, like those in other non-Western societies,
find psychiatric and psychological intervention (Fabreka, 1991) and family
marital therapies (Savaya, 1995) stigmatizing. This is especially true of
stigma of mental health services could damage their marital prospects,
increase the likelihood of separation or divorce, or, especially among Muslims,
used by a husband or his family as leverage for obtaining a second wife (Al-Krenawi,
1998a; Al-Krenawi et al., 1997; Bazzoui & Al-Issa, 1966; Chaleby, 1987a;
Okasha & Lotailf, 1979). Stigma may be avoided or reduced by integrating
mental health services into nonstigmatizing frameworks or physical settings,
such as general medical clinics (Al-Krenawi, 1996).
Cultural expectations regarding gender can complicate the
helping relationship. Arab men may have difficulty accepting a female social
worker's directions. When this problem occurs, it does not arise necessarily
from the male client himself but may arise from a male family member in
a position of authority such as a father, uncle, older brother, or any older
member. Of Iranian families, Jalali (1982) wrote "the patriarchal organization
of the family is to be acknowledged by addressing fathers first and as the
head of the family. The social worker should not attempt to change cultural
power hierarchies or role patterns since this will alienate the family" (p.
An opposite-gender client relationship is complicated and
may be impractical. But even when a positive connection is established
and the client settles into the professional helping process, he or she might
soon open up and get attached, which leads to conflict or confusion. Every
should be made to educate the client about the appropriateness of the attachment,
and reassurance should be offered that the relationship is protected by
standards. Likewise, a female-male social worker-client dyad is best responded
to with such culturally appropriate techniques as referring to the client
sister," maintaining minimal eye contact and appropriate physical
distances between client and worker, and integrating the family in many,
if not all,
stages of treatment (Al-Krenawi, 1996).
Cultural differences between the traditional Arab societies
and Western society also are expressed in the nature of interpersonal contacts.
For the Arab client it is very difficult to accept the formal distance between
worker and client that is the norm in modern helping situations, and it may
be that the worker will have to bend principles. For the ethnic Arab, it is
more important to build a relationship than to solve a problem. Relationships
are built through the Arab conception of trust. Once clients trust the social
workers, a helping alliance can be developed and maintained (Durst, 1994).
In situations where the client and social worker are of the
same gender, the social worker should take into consideration the client's
need for expressions of intimacy and occasionally relax the formality that
is the norm in Western helping. Conversely, when the social worker and
client are not of the same gender, the former should maintain even greater
than normal, for fear of invoking sexual impropriety (Mass & Al-Krenawi,
1994). Minimal eye contact may occur as a result (Al-Bostani, 1988; Rizvi,
1989) and should not be interpreted as client resistance to treatment.
Interventions and Context
Contrary to a Western therapeutic emphasis on the individual,
all interventions with Arab clients need to be couched in the context of the
family, extended family, community, or tribal background.
Modern talking therapy is an extension of the development
of individualism, nurtured by the liberal political climate of democracy
(Monte, 1995). It presents the individual as an independent entity whose
opinions, and values must be respected. Not surprisingly, "self-realization" has
been an important therapeutic and epistemological goal for decades (Fromm,
1941, 1946; Pedersen, Fukuyama, & Heath, 1989).
As several scholars have pointed out, one of the most important
dimensions of intracultural differences is whether a culture is individualist
or collectivist (Georgas, 1989). In individualist cultures in the West,
during the course of development individuals undergo an important psychological
separation from their parents, and as an integral part of this process, they
form a unique
and autonomous identity (Erikson, 1963; Mahler, 1968). A similar process
of personal development does not occur in the same way in collectivist cultures
in Africa, Asia, South America, or the Middle East (Sue & Sue, 1990).
Nor does it among Arab peoples, where the group or family identity remains
focus and the individual remains embedded in the collective identity (Hofstede,
Individuals' interests unite with those of their group of
allegiance, and the general good supersedes the personal. Individual problems
draw the members of the group in common pursuit of solutions. Individuals in
trouble do not choose, in isolation from others, among alternative courses
of action. The importance of the group is reinforced in daily interactions.
Rather than adopting Euro-American ideals of conjugal isolation and withdrawal
from the extended family, Arab social structures are dominated by daily interaction
with near and extended kin (Holmes-Eber, 1997).
Individuals can be perceived only through the group to which
they belong (Barakat, 1993). Whereas a Western individual may internalize
social rules and rely on internally derived guilt to amend inappropriate
behaviors, an Arab individual is more likely to be sanctioned by external-oriented
stemming from the attitudes of others (Gorkin, Masalha, & Yatziv, 1984).
The mingling of the individual and the group, and the acceptance of the sociocultural
norms and values of that group, have certain advantages at the psychological
level. The group gives the individual protection and security, a feeling of
belonging and identity, as well as emotional and practical support during crises
(Barakat). A drawback is the diminished sense of "self." The
fate of an individual with ambitions or desires that do not fit in with
or values of the collective, is likely to be isolation or even ostracism
(Chaleby, 1987b). Thus, a social worker needs to incorporate people, other
the identified patient or client, in both the construction and resolution
of problems, and also, where relevant in the actual processes of helping.
The family's involvement in individual mental health helping
is considerable, and often makes the social worker's work more complicated.
The family unit is sacred among Arab peoples, who are raised to depend
on it as a continual source of support. Extended family members are highly
as well. They are expected to be involved and are consulted in times of
crisis. When a family member is sick, the restoration of health is of concern
other members. As pointed out by Meleis and La Fever (1984), although Arabs "value
privacy and guard it vehemently . . . their personal privacy within the family
is virtually non-existent . . . Decisions regarding health care are made by
the family group and are not the responsibility of the individual" (p.
76). In some cases the family will intervene on behalf of the identified
patient, although they too lack in trust, whereas they expect much. For
might try to control the interview by answering the questions directed
at the client while they withhold information that may be perceived as
The family members' involvement easily can be experienced as arrogance,
verging on insult, when they act as authorities on matters that pertain
to the social
worker's area of expertise.
These cultural constructions of family can best be used by
social workers' willingness to tolerate the enmeshment so characteristic of
Arab families, by educating themselves regarding Arab family values so that
they can in turn sensitively educate the family about the necessary requirement
for a workable helping relationship. Practitioners working with an Arab individual
by necessity will come into contact with the family and need to reconsider
what might otherwise be seen as an Arab family's overinvolvement, overprotection,
blatant codependency, or enmeshment. These characteristics, in fact, may well
be highly appropriate in a culture where any less involvement would be considered
neglect if not abandonment.
If the cultural gap is too great, involving a cultural consultant
(Budman et al., 1992)a member of the culture who can mediate between
the family and the practitionersmight be advisable. The chosen consultant
may be affiliated with the mental health agency, a different agency, or may
be a member of the community, but in all instances, he or she would have to
be deemed suitable by the family. The consultant, in turn, "translates
for the staff the symbolic meanings of behaviour and action, and clarifies
cultural properties, can be invaluable to treatment planning, and a key factor
in staff acceptance of the patient" (Meleis & La Fever, 1984,
Arab clients' communications are restrained, formal, and impersonal.
Clients' idioms of distress might rely on a complex system of metaphors
and proverbs. Arab clients may use a variety of ethnospecific idioms of distress.
They may describe a depression as "a dark life," or their fear by
saying "my heart fell down." Likewise, proverbs are often used. One
client, for example, described an inability to confront personal problems as "my
eye is blind and my hand is short" (Al-Krenawi, 1998a). Client communication
also may appear to be indirect, circular, and nonspecific (Al-Krenawi,
Arab communication styles are formal, impersonal, and restrained,
rather than candid, personal, and expressive. It is also difficult for an Arab
client to divulge personal problems and feelings to someone outside of the
family or community. To do so is to be seen as weak, disloyal, or both (Al-Issa,
1990). Thus, several techniques commonly used in Western cultures have limited
application to Arab clients. Self-disclosure, client affect, and self-exploration
are often difficult, particularly if they are perceived as risking damage to
family honor. These difficulties should not be construed as client resistance.
Arab clients also interpret the social worker's messages according
to their own cultural codes, which may be different from those of the worker
(Sharp, 1994). Not surprisingly then miscommunication between the client
and a social worker unfamiliar with the client's culture can occur (Al-Krenawi,
Maoz, & Reicher, 1994; Eisenbruch, 1991). Difficulties in communicating
and deciphering the client's verbal and nonverbal messages can lead to errant
assessments, because of the existence of culture-bound symptoms and syndromes
(Al-Krenawi & Graham, 1997c; Bilu & Witztum, 1995) and the choice of
approaches and techniques of practice that may be unsuitable for the client's
cultural perceptions. This is one of the reasons for early termination of treatment
or nonuse of mental health services (Al-Krenawi, 1999a; Al-Krenawi & Graham,
1996b, 1997c; Savaya, 1998; Sue & Zane, 1987).
Length of Treatment
Treatment is most successful when it is short term and directive.
A social worker who maintains too rigid a time frame could be perceived
as being cold or unreasonable. In Arab societies helping has a more explanatory
and instructional character. Arab clients expect social workers to be like
teachers, to explain conditions and supply information concerning problems.
Preference for the instructional-explanatory model for treating Arab clients
is linked to the society's child-rearing methods, the instructional methods
used in its schools, and its hierarchical structure. Children learn to
advice and assistance from those more senior in age and status and repeat
these patterns throughout their lives. The process of child development rests
guidance from the father, the mother, and other adults in the nuclear and
extended families and even in the clan. This guidance is usually expressed
in the form
of "do's" and "don'ts" and assertions that "this is
right" and "that is wrong," with little explanation or justification.
Such a process may inhibit children from coping independently with their problems
or from learning experientially (Hatab & Makki, 1978). Rather, the
child tends to learn to obey by means of punishment and reward.
Arab clients and their families place a great deal of responsibility
on mental health practitioners to provide solutions to problems with little
or no input from the client. The Arab client generally will view social
workers as genuine figures of authority and conform to what is advised or prescribedat
least on the surfacebecause disagreement is equated with confrontation,
which is considered rude. The mental health provider can expect the Arab
client to remain passive during the assessment interview and the helping
Not surprisingly then, clients expect social workers to explain
the nature of their problems and to supply solutions, rather than trying to
discover solutions for them. Thus, helping should be direct and clear, with
concrete targets. It should provide guidance, advice, direction, explanations,
and instructions. In addition, social workers should develop techniques to
encourage trust and openness between client and practitioner. Behavioral and
cognitive therapies are obviously more suited than psychodynamic approaches.
Issues of Temporality
Temporal issues need to be constructed differently for ethnic
Arab people than for people in Western nations. Social workers should
be aware of the Arab concept of time and help prevent this from becoming a
barrier to effective service.
Differences in temporal perceptions can produce challenges
in working with ethnic Arab families. In a clinical or hospital setting
in particular, families may have difficulty with limited visiting hours, which
may have to be extended. Ethnic Arab people's notions of time are more
and not as structured or determined as they are in the West. Ethnic Arab
peoples, as a result, may not be very time bound. In Arabic languages, there
clear distinctions among various forms of past and future. As Patai (1973,
cited in Kulwicki, 1996, p. 195) explained, "it is almost as if the past
were one huge undifferentiated entity, within which time distinctions are immaterial
and hence not noticed and which, almost imperceptibly, merges into the present
and continues into the future" (p. 70). Psychologically speaking this
view can be viewed as advantageous in that it fosters flexibility in one's
adaptation to life circumstances, with an ability for prompt readiness
when facing the unforeseen. It is a disadvantage, however, when the culture
which one lives requires a time-sensitive attitude.
Thus, making and keeping appointments at fixed times or starting
and ending sessions promptly might be a source of difficulty. Short-term
helping may also be preferred to long term. Arab clients may not show up
at a precise time, and the exact duration of a session may need to be more
fluid than in a Western context (Sue & Sue, 1990).
Social workers should reconsider what would constitute intrusion
to helping or on the privacy of the client based on the client's expectations
and not on Western standards. Social workers would do well to clearly establish
early on what the rules are regarding appointment times, lateness, and missed
sessions. This will be part of the social worker's role as an educator in the
process of treatment, the social worker's role, expertise, and goals.
Views of Mental Health Services
Clients of ethnic Arab origin have a negative view of mental
health services and may tend to mistrust and underuse them. Although there
exceptions, based on level of education and degree of acculturation, it can
be safely assumed that most ethnic Arab people view mental health services
in a negative light, and consequently use of mental health services is limited.
Ethnic Arab peoples, particularly in Arab countries, do not distinguish among
psychiatrists, psychologists, or other professionals in the mental health field.
All tend to be viewed suspiciously as researchers or as doctors who discard
religious values and fail to see these values as a genuine source of solace
and healing. In such a context, it may be difficult to establish trust. There
is no inherent notion that the social worker-client relationship could include
a sincere emotional connection that involves mutuality, let alone the idea
that such a relationship has a central helping and healing value. These need
to be included, explicitly, in any treatment process.
A cultural gap leading to mistrust is a given when a non-Arab
mental health provider comes into contact with an ethnic Arab client (Al-Krenawi,
1999a, 1999b). Therefore, social workers' first task is to educate themselves
about the religious, cultural, and national background of the client. Aside
from the individual background, an understanding of topics such as the Arab
view of health and medicine, including mental health, the Arab family system,
Arabs peoples' opinions of Western society, Americans' view of ethnic Arab
people, and ethnic Arabs' use of traditional healing systems might assist the
practitioners in better understanding ethnic Arab clients.
Somatization of Affective Disorders
Ethnic Arab clients often view affective disorders as having
somatic origins. Therefore, they expect mental health treatment to be similar
to physical or medical treatment in its timeliness and in its lack of demand
for client contribution.
As explained by Kulwicki (1996), "Arab-American clients
often expect doctors to make medical decisions without the need for the collection
of a medical history and without consultation with the client. In cases where
clients are asked to participate in decision making about their medical regimen,
they may lose trust in the medical experts and discontinue treatment" (p.
201). The client might wait to be questioned by the social worker, may not
complain much about emotional distress, but might do so for physical ailments.
Because their psychological symptoms often are experienced and interpreted
physically rather than emotionally, Arab clients frequently expect to be "cured" of
symptoms without having to divulge many aspects of their personal lives,
much as they would when seeking a physician's help for physical ailments.
it is frequently a physician who makes the referral. If the client follows
through with the recommendation, it is either with much ambivalence or
as a desperate attempt to restore health, neither of which may be conducive
a long-term positive connection. Therefore, it is important that the practitioner
stay very close to the here and now and be prepared for the possibility
Depression and somatization are so intertwined in Arab culture
that it is almost impossible to separate them in two distinct categories, as
is done in the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 1994). Indeed, as cross-cultural studies of depression
so far have indicated,
The experience and expression of
depression varies across ethnocultural boundaries. Reviewers concur that
feelings of guilt, self-deprecation, suicidal ideas, and feelings of despair
are often rare or absent among non-European populations, whereas somatic
and quasi-somatic symptoms, including disturbances of sleep, appetite,
energy, body sensation, and motor functioning, are more common. (Marsella,
Sartorius, Jablensky, & Fenton, 1985, p. 306)
of conflict, whether internal or external, and the expression of negative
feelings are not well accepted in the Arab culture. The anxious self-absorption
that often accompanies a depressed mood is viewed negatively as "thinking
too much," which is in turn viewed as a narcissistic preoccupation.
Physical symptoms, however, are accepted as legitimate and morally acceptable
expressions of pain. Even the way the language is used lends itself to a
confusion of psyche and soma, as depressive symptoms are depicted in physical
imagery, especially involving the chest and abdomen. For example, as pointed
out by Bazzoui (1970), "the average Iraqi patient describes his depression
as a sense of oppression in the chest, a feeling of being hemmed in, or in
other cases, a hunger for air. On being asked if he feels sad, downcast or
depressed, one is struck in many cases by the unawareness of the patient
of his mood" (p. 196).
In the West,
when treating depression as described in the DSM-IV, the practitioner looks
for mood symptoms such as depressed mood or loss of interest in most activities;
physical symptoms such as fatigue, insomnia, changes in appetite; and cognitive
symptoms such as excessive guilt, feelings of worthlessness, and preoccupation
with death. The literature on affective and somatic disorders in Arab countries
seems to lack mood symptoms for both depressed and manic or hypomanic clients
(Al-Issa, 1995; El-Islam, 1989, 1994). That is, when the client is asked
if he feels sad or elated, he generally answers "no" or perhaps "I
don't know." Similarly, a lack of cognitive symptoms has been noted,
especially those associated with guilt and loss of self-esteem. So, whereas
a client may feel incapacitated by psychomotor retardation, extreme fatigue,
and other physical symptoms, he will not interpret these as mood related,
which would be a typical interpretation in Western nations.
condemns suicide, and clients may not divulge suicidal feelings easily. Dubovsky
(1983), working in Saudi Arabia as a psychiatrist, discovered that "if
asked directly if they are having thoughts of killing themselves, most depressed
patients reply that they are good people and would never entertain such thoughts.
If, however, potentially suicidal patients are asked if they wish that God
would let them die, they usually will reply in the affirmative" (p.
are needed for work with the somatic client. These clients may be passively
dependent on the mental health professional. They may seek a cure, usually
of a medicinal kind, and may be reluctant to discuss their personal concerns
or difficulties. Behind this resistance often lies a fear of embarrassment
or of shaming the family. As Racy (1980) discovered while working with Arab
Muslim women in Saudi Arabia, "much effort is required to break through
the barriers of somatization and passivity in order to get any specific picture
of that particular patient's life . . . when such effort is successful, one
frequently is able to discover . . . feelings of loneliness on separation
from parents and siblings . . . fatigue from prolonged child-rearing, and
conflicts with in-laws" (p. 214). He suggested that the practitioner
may effectively use a client's passivity as well as the authority placed
in the social worker to engage the client in her own treatment, such as having
her keep a diary or perform certain tasks or assign an exercise regimen.
Role of Religion in Interventions
is an important context in which problems are constructed and resolved. Consideration
must be given to the role of religion in Arab societies, whether Islamic,
Druze, or Christian. Social workers should be aware of how religion relates
to topics often raised by clients such as spirits, sorcery, and the devil.
Adherents to most Arab religions could believe that an illness is divine
punishment (Nasr, 1966).
In many Arab
communities, people believed to be mentally ill may be viewed as not quite
human and not quite angelic but are associated with the supernatural. In
Denny's (1985) words "they are feared by humans, for they are associated
with the spooky and uncanny dimensions of life" (p. 93). This is to
suggest that mental illness is regarded with some respect and fear of God.
Social workers also should appreciate how a religious outlook could cultivate
a conservative approach to family problems, marital problems, family matters,
and the education of children. Thus, religious concepts may often be explicitly
incorporated in the helping process.
Concept of Psychosocial
clients' concept of their psychiatric or psychosocial problems may be that
the origin of them is biomedical, human, or supernatural. Particular emphasis
often is placed on an external locus of control. Ethnic Arab clients tend
not to see the origins of illnesses from a biomedical point of view but rather
as resting with an external locus of control (Al-Issa, 1995; Al-Krenawi & Graham,
1997b, 1997c; Chaleby, 1987b). For example, physical or mental sickness or
family or marital problems could result from several external causes. These
include the intervention of supernatural elements such as spirits or the
participation of other people with the supernatural through such avenues
as the evil eye or sorcery ( Al-Krenawi, 1999b; Al-Krenawi, Graham, & Maoz,
1996; El-Islam, 1982; Morsy, 1993; Sanua, 1979; West, 1987). Druze, as a
different example, believe in the transmigration of souls and could conceptualize
a mental illness as punishment from a previous life (Daie, Witztum, Mark, & Rabinowitz,
1992). Among Arab religions angels are believed to exist and to be important
helpers of God. Denny (1985) explained:
most of the great angels are good creatures of God, one is evil. That is
Satan, who was cast out of heaven after he refused God's command to bow
down to Adam . . . The angels, which have no sex, are made of light, whereas
humans are created from clay . . . In addition to the angels are the supernatural
beings, created of fire, known as jinn . . . the invisible beings
that possess poets, filling them with special awareness and power in speech.
One who is possessed by a jinni is rendered majnun, meaning
insane (p. 93).
on Arab clients indicates no correlation between clients' educational level
and their perception of the problem or mental illness as caused by supernatural
forces (Al-Krenawi, 1999a; El-Islam & Abu-Dagga, 1992; Khalifa, 1989).
should appreciate the etiology of the problem or illness from the perspectives
of the clients, their families, and the society to which they belong. Their
explanatory model, derived from their cultural and religious realities is,
in this sense, an informal theory. The social worker's knowledge and skills
are based on a formal theory (Al-Krenawi, 1998b). The practitioner could
bridge the gap between formal and informal theories, as the informal theories
have strong resonance with clients and their families. Such bridging could
include using clients' idioms of distress in the intervention process (Bilu & Witztum,
1995), and it also could include incorporating traditional healing with the
modern helping process and incorporating the clients' perceptions of etiologies.
Ethnic Arab Clients' Use
of Mental Health Services
use mental health services and traditional healing concurrently or in succession.
Informal systems in ethnic Arab societies should be regarded as complementary
to modern mental health systems rather than competitors. Indeed, Arab clients
have developed a strategy of dual use, in which modern and traditional biomedical
systems are consulted concurrently or in succession (Al-Krenawi & Graham,
1996a, 1996b, 1997c). The choice between the modern mental health services
and the traditional systems is not left entirely to the client (El-Islam,
1994). Usually family members accompany the client in the process of seeking
help and determine the pathway to care for or with the client. The professional
literature indicates that Arab clients often make use of informal systems
before turning to modern mental health treatment. Therefore, traditional
healing can be integrated readily into a helping process with clients of
various cultural backgrounds (for example, by adopting some of the religious-cultural
rituals of Arab societies).
healers tend to treat spiritual-mental aspects, whereas workers from biomedical
health systems may be more closely linked to somatic aspects, expressed by
physical disorders. Arab traditional healers include, but are not limited
to, al-fataha or female fortune tellers; the khatib or hajjab,
male healers who produce amulets that are worn on the body to ward off evil
spirits; the Dervish, male or female healers who treat mental illness
using a variety of religious and cultural rituals; and moalj belkoran, male
Koranic healers who use Islamic scripture as a basis of warding off evil
spirits (Al-Issa, 1990; Al-Krenawi & Graham, 1996a, 1996b; El-Islam,
1982; Gorkin & Othman, 1994). Thus, where appropriate, practitioners
could integrate activities of traditional healers into modern helping or
validate their use by clients and their families (Al-Krenawi & Graham,
1999a, 1996a, 1996b).
practitioners can learn much from traditional healers, particularly with
respect to working with families. They could also collaborate effectively
with traditional healers in Arab communities. Traditional healers are part
of the client's culture. Healer and client share a common worldview that
stresses the importance of their joint origin and helps them understand the
problem, its sources, and the best ways of relating to it. The element of
worldview is an important factor in the traditional system's efficacy (Torrey,
healing systems, the healer is active, and the client is passive. The healer
directs, advises, guides, gives instructions, and suggests practical courses
of treatment, such as rituals, incense burning, or visiting saints' tombs
(Al-Krenawi & Graham, 1996a; El-Islam, 1982). The client sees the traditional
healer as a figure of authority and charisma and also as a supportive and
understanding father figure. Traditional healers often develop good relations
with the client, which reinforces the client's belief in the healer's supernatural
powers (Al-Krenawi & Graham, 1996a, 1997b, 1997c; El-Islam, 1982).
healer engages the help of the client's family as partners in the processes
of treatment and healing, as spokespeople for the client. The healer can
engage the family's help effectively in seeing that instructions are carried
out and in reporting back on the client's condition (Al-Krenawi & Graham,
1997c). Traditional healers are particularly skilled in identifying and using
the dominant figure in the client's family, enlisting that person's help
in bringing about change in the client and in mobilizing the family and community
to this end. Such methods are not widely used in modern mental health systems,
which often are characterized by detachment and by the lack of cooperation
between the social worker and the client's family (Al-Krenawi & Graham,
as a growing body of interdisciplinary research shows, there are several
important facets of mental health practice with Arab clients. These include
taking into account gender relations, the individuals' place in their families
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in the West, the clients' level of acculturation. Such aspects provide the
basis for specific guidelines in working with Arab mental health clients:
an emphasis on short-term, directive treatment; communication patterns that
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About the Authors
Alean Al-Krenawi, PhD, is
senior lecturer, Department of Social Work, Ben Gurion University of the
Negev, Beer-Sheva 84105 Israel, e-mail: firstname.lastname@example.org. John
R. Graham, PhD, is associate professor, Faculty of Social Work,
University of Calgary, Calgary T2N 1N4, Canada. Send correspondence to
A. Al-Krenawi, Department of Social Work, Ben Gurion University of the
Negev, Beer-Sheva 84105 Israel.
Accepted June 17, 1999