Understanding and Addressing Arab-American Mental Health Disparities Sherief Y

Scholarly Undergraduate Research Journal at Clark

Volume 3 Article 1

April 2017 Understanding and Addressing Arab-American Mental Health Disparities Sherief Y. Eldeeb Clark University

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Recommended Citation Eldeeb, Sherief Y. (2017) "Understanding and Addressing Arab-American Mental Health Disparities," Scholarly Undergraduate Research Journal at Clark: Vol. 3 , Article 1. Available at: https://commons.clarku.edu/surj/vol3/iss1/1

This Review is brought to you for free and open access by the Scholarly Collections & Academic Work at Clark Digital Commons. It has been accepted for inclusion in Scholarly Undergraduate Research Journal at Clark by an authorized editor of Clark Digital Commons. For more information, please contact [email protected], [email protected]. Understanding and Addressing Arab-American Mental Health Disparities

Cover Page Footnote I am extremely grateful for the assistance given by Dr. Esteban Cardemil for his insightful comments during the development and review of this work, as well as his assistance in setting up the interview included in this work. Furthermore, I am grateful to the panel of mental health professionals that were interviewed and for the assistance of Cindy Mohnblatt rB onstein in conducting the interview. Finally, I would like to express my appreciation to my friends, family, and girlfriend for their endless support. The uthora does not have any sources of financial support to disclose in regards to the creation of this work.

This review is available in Scholarly Undergraduate Research Journal at Clark: https://commons.clarku.edu/surj/vol3/iss1/1 MANUSCRIPT Understanding and Addressing Arab-American Mental Health Disparities Sherief Eldeeb ‘18 | Psychology

ABSTRACT The landscape of mental healthcare and focus on disparities research in the United States has vastly improved in recent years. However, Arab-Americans continue to be a commonly overlooked group within the scope of research. This trend is especially worrisome given the detrimental factors for Arab-Americans that have arisen as a result of 9/11 and the 2016 United States Presidential Election. This work explores barriers to accessing formal mental health care and offers recommendations to reconcile them for Arab-Americans. The present study completes this through a review of the literature and an interview conducted by the author of a panel of mental health professionals at a community health organization in order to gain a contemporary perspective of the issue. Salient suggestions that arise from this study are reducing stigma in the community by incorporating increased usage of primary care and religious providers as well as family therapies; the allocation of Arabic-speaking translators to clinics or a focus on hiring Arabic-speaking practitioners; supporting safety-net insurance funding; increased education on what psychotherapy and mental illness are within this community; and pushing the necessity of professional training in the culture, religion, and therapeutic preferences of Arab-Americans.

With every passing American Institute, 2011; Mrazek group within the main focus of generation, some barriers to & Haggerty, 1994). Once those disparities research. This proves mental healthcare have slowly barriers were identified, the goal troublesome for the approximately been removed for the majority was then to synthesize the 3.7 million Americans of Arab of Americans, and the landscape perspectives of the literature and descent today, which has rapidly of healthcare as a whole has the author in order to address grown by 47% within the last made vast improvements from how to reduce them. To help decade (Arab American Institute the days of old. Mental health is achieve these goals, an interview Foundation, 2011; US Census now seen as a prominent issue on was conducted with a panel of Bureau, 2011). Unfortunately, a national scale through parity mental health practitioners at a there are limitations with these agreements that would have been local community health organiza- estimates as the United States inconceivable years ago. However, tion in a large Northeastern city does not federally recognize these improvements have not in order to supplement the views Arabs as an ethnic group, instead applied to all Americans equally. in the literature with a more considering them “White” or Like many ethnic minorities, contemporary perspective. The “Caucasian.” These estimates are Arab-Americans face distinct panel was composed of one then drawn from reported barriers in accessing formal mental supervising licensed social countries of origin instead of healthcare. The aim of this paper worker, two clinical psychology self-report. Because of this, much is to examine why Arab-Amer- students on internship, and two of the research drawn from Arab- icans seem to be so unwilling, social worker students on intern- Americans has been conducted or unable, to seek formal mental ship. The interview lasted 35 in the state of Michigan, as the healthcare services. This question minutes. Questions were deter- category is recognized there. is especially pertinent given the mined a priori by the author, but This is an important limitation tendency of Arab-Americans were expanded based on the inter- to consider throughout this to have protective factors, or viewees’ responses. This interview report; however, specific efforts attributes that reduce the risk was approved by the IRB at the were made by the author in order of mental illness, of increased author’s institution. to gain a more holistic view of wealth and education compared Arab-Americans are a the Arab-American experience to the average American (Arab- less frequently studied ethnic across the United States.

11 ARAB-AMERICAN MENTAL HEALTH DISPARITIES: Sherief Eldeeb

RECENT TRENDS AND seeking formal mental health care. discrimination in the United DEMOGRAPHICS OF ARAB- States, with most of them AMERICANS ARAB-AMERICANS AS A attributing it to 9/11. Risk factors In order to gain a better DISTINCT GROUP OF STUDY associated with reporting an understanding as to why this group The study of Arab- adverse event included being has a unique need for study, a Americans as a distinct ethnic Arab, Muslim, or wearing better understanding of Arab- group from “White” Americans traditional clothing. Furthermore, American’s recent history is is essential due to heightened risk 56% of the immigrants had faced necessary. Arab-Americans of media bias and discrimination persecution in their home generally immigrated to the United that can lead to negative ethnic country, and 54% of those States in three waves, though the identity (Jackson, 1997). This reporting an adverse event had third wave is the most pertinent issue is especially relevant given symptoms similar to a PTSD to this review. The third wave the rise of hateful speech towards diagnosis. However, despite of immigration occurred after Muslims and Arab-Americans such large numbers reporting the 1967 Six-Day War between since 9/11 (Persson & Musher- experiencing these negative events, Israel and several Arab nations, Eizenman, 2006) and the 2016 many of the study participants leading a large influx of Arab United States Presidential Election. described that professional (mainly Palestinian) immigrants One of the most shocking pieces mental health services were not to flee to the United States. This of literature to emerge as a result an option for them (Reimann, wave continues to this day, and of 9/11 was a survey conducted Rodriguez-Reimann, Ghulan, & has reached a greater influx with by Amer and Hovey (2011) that Beylouni, 2007). Barriers must be recent turmoil in the area includ- found that across 35 states, 50% identified in order to understand ing the Arab Springs, the wars of Arab-Americans met symp- and address what is keeping in Iraq and Afghanistan, and the toms of depression and almost Arab-Americans out of mental Syrian Civil War (Abraham, 1995; 25% of the surveyed Arab- health treatment even when Vermette, Shetgiri, Al Zuhieri, & Americans met symptoms facing such appalling circumstances. Flores, 2015). It is important to of moderate/severe anxiety. note that although the majority of Previous to this, Amer (2011) ARAB- AND MUSLIM- AMERICAN Arab-Americans are not Muslim also found that Arab-Americans MENTAL ILLNESS (about 23% are), the vast major- had significantly higher rates CONCEPTUALIZATION ity of recent Arab immigrants to of anxiety, depression, and An understanding of how the US are indeed Muslim, and acculturative stress post-9/11 as this population conceptualizes so this percentage may not be compared to before the event. mental illness can provide a key truly representative of the current A study of Arab-American insight into what help-seeking population of Muslim Arab- adolescents corroborated these pathways they undertake. In Americans in the United States results, finding that 14% of them one study of Muslim American (Bagby, Perl, Froehle, 2001). reported symptoms matching a individuals, the prominent Moreover, much of the research diagnosis of moderate or severe conceptualizations that emerged examining Arab-Americans has depression, compared to 8% were based in biological, religious, used samples that were majority in the same age group of other supernatural, and environmental Muslim, sometimes reaching 96 ethnicities. Importantly, 35% of models (Bagasara & Mackinem, and 97% (Aloud, 2004; Jaber et the study participants stated they 2014). The most dominant model al., 2015; Vermette et al., 2015). would never consider speaking to was the biological one, but on Due to these factors, even though a health professional about mental closer examination through Muslim Arab-Americans are not health (Jaber et al., 2015). This open-ended response, it was the main focus of this paper, it story took a turn for the worse found that the religious and seems essential that factors affect- when a study of Arab- and East- supernatural models were also ing Muslim Americans will also ern African-immigrants to the pervasive in the population. A be observed in order to gain a United States in San Diego found frequent theme in the study was holistic view of the detriments that 37% of the participants a multi-dimensional view that that keep Arab-Americans from reported an adverse event or had components of each model

12 Scholarly Undergraduate Research Journal at Clark University | Volume III interacting with one another in even an individual’s health can or Sheikh, 11% preferred formal order to form an understanding be seen as not as important if it mental health services, and of mental illness (Bagasara jeopardizes the family in any way 6% stated they would not seek & Mackinem, 2014). This (Gorkin et al., 1985; Shalhoub- help at all. This finding runs in multi-faceted model was also Kevorkian, 2005). The focus of an contrast to much of the literature found in a study of Muslim extended family in Arab culture noting preferences for familial Arab-Americans, and so has a is attributed as a large source of help-seeking, but it is not com- more applicable nature for the social support for individuals pletely out of expectations. Aloud purpose of this paper (Aloud, and, as such, is typically the main (2004) speculated that medical 2004). In a similar study of pathway in which treatment is doctors were the most favored in Muslim Arab-American illness sought out (Abraham, 1995). For this sample due to the greater conceptualization, it was found example, in one study of Iraqi emphasis on the biological con- that the spiritual model was the refugees in Texas, participants ceptualization of mental illness most commonly reported illness noted that the family was the among the studied population, conceptualization, whereas the best suited to handling most the influence of somatization biological model became the mental health problems. Many of and conversion disorders, and most prevalent when speaking the participants noted that they the fact that the sample reported about experiences either the would only seek help from other higher levels of education. Smith participants, or their friends or sources if the problem became (2011) reported that individuals family, had (Smith, 2011). Perhaps too severe, in which case they that had a stronger belief in the tied to this biologically dominant would typically seek a Primary biological model of mental illness view is the frequently reported Care Provider (PCP) (Vermette et tended to prefer medical doctors somatization and conversion al., 2015). This finding is corrob- as the primary source of care. disorders of Arab individuals. orated with the results of another In other words, it is reported study which found that some Religion. that Arab-Americans frequently participants reported it was seen Through focus group display physiological symptoms in as inappropriate to speak about discussions of Muslim Arab- response to psychological distress secrets outside of the family Americans, Smith (2011) noted (Al-Krenawi & Graham, 2004). (Smith, 2011). This dependence that the most frequently reported on family is so prevalent within source of care reported in her PREFERRED HELP-SEEKING the Arab help-seeking process sample was through a religious SOURCES that in some cases individuals or faith healer. This was especially Family. could even be ostracized for seeking true if the individual had stated It is important to note help through formal services as it an illness conceptualization that the literature on preferred was seen as attempting to actively based on a religious or spiritual help-seeking sources in the circumvent the family structure model (Smith, 2011). Aloud Arab-American community is (Abuddabeh, 1995). However, (2004) found that there was mixed. Therefore, the most com- other studies have conflicted with a strong inverse relationship monly reported sources of help- this finding of family as the most between help seeking prefer- seeking will be explored here. The used help-seeking source (e.g. ences and attitudes toward formal most common source of reported Aloud, 2004). mental health services among help-seeking in Arab-Americans the sample he recruited. This was is through the informal source Medical Doctors. corroborated by a follow up study of family (Abudabbeh, 1996; In a survey of help- conducted by the author in which Kulwiki, June, Schwim, 2000; seeking preferences and attitudes formal mental health services Smith, 2011; Vermette et al., for mental health disorders, were less preferred by the ques- 2015). This is consistent with the Aloud (2004) found that Muslim tioned sample (Aloud & Rathur, theory in the literature stating Arab-Americans reported that 2009). Therefore, individuals that Arab values typically align 33% preferred medical doctors, tended to exhaust all informal along the family far more than 22% preferred family, 19% mental health care sources the individual, so much so that preferred approaching an Imam before attempting to reach for

13 ARAB-AMERICAN MENTAL HEALTH DISPARITIES: Sherief Eldeeb

formal services. The complaint experienced mental illness, they (Kira, Lewandowski, Ashby, of participants in multiple studies were more likely to attribute it to Templin, Ramaswamy, & that formal mental health services the biological model and seek a Mohanesh, 2014). Arab-American providers did not have prereq- PCP (Aloud, 2004; Smith, 2011). participants also noted significant uisite knowledge of the Islamic Some also argue that somatization “feelings of shame” in regards to religion displays the importance can serve as defense mechanism the seeking mental health services of this aspect in the preference against the stigma of a psychiatric (Aloud & Rathur, 2009, p. 93). of help-seeking behaviors, even diagnosis through the presentation Arab-American females in cases where it was not the of physical symptomology seemed to face unique stigma dominant model of the individual (Hotopf, Wadsworth, & Wessely, specific to their gender. Smith (Aloud, 2004; Reimann et al., 2001). (2011) and Al Krenawi and 2007; Smith, 2011; Vermette et The effects of stigma colleagues (2000) both noted al., 2015). could even reach into the therapy the hesitation of some women room as there were reports of to seek mental health services BARRIERS TO ACCESSING FORMAL interpreters shaming the patient due to the possibility that it could MENTAL HEALTH SERVICES for speaking about mental illness harm their marriage opportunities. Stigma. both in the literature (Vermette This stigma can be seen in an By far, stigma is one of et al., 2015) and in the interview excerpt from the interview con- the most prevalent themes within conducted by the author. Stigma ducted by the author in which the the literature as a barrier for seemed to be amplified when mental health provider noted Arab-Americans. Stigma is so Arab-American communities were prevalent and damaging that one small (Vermette et al., 2015). I2: “we’ve had phone interpreters study found that, without regards This was best summarized in the who have shamed our clients to socioeconomic status or interview conducted by the throughout therapy and…when education level, it was the author in which the mental we ask questions about like most reported barrier in Arab- health provider noted: sexuality and you know a Americans (Aloud, 2004). At the female Iraqi woman is responding very root of the issue is the fact I2: the Middle Eastern community and this interpreter was like you that the word crazy, or majnoon in [city] is so tiny, umm and they should not be speaking like that.” in Arabic, is heavily stigmatized all know each other regardless if within Arab culture (Gorkin they knew each other before, but Stigma in relation to et al., 1985). In focus group just through health care here and family had multiple dimensions. discussions, individuals reported maybe going to the same mosque Individuals feared seeking mental fears that others would view them or maybe going to the same stores, health services in order to not as “weak” or that they “had they end up knowing each other harm the reputation of their nothing better to do” if they so they will maybe see each other family (Smith, 2011). However, sought therapy (Smith, 2011, pp. in the waiting room and get really individuals also feared stigma 64-65). This was clarified by uncomfortable. within the family due to the participants in that study to not aforementioned expectation that have anything in particular to Kira and colleagues they should be the main source do with Islam, but was rather a (2014) noted that internalized of care and, in some cases, how cultural stigma within the Arab stigma was also an issue for Arab- they could be ostracized due to community (Smith, 2011). In a Americans, Muslims, and refugees, the view they were attempting to separate study, both providers stating that those groups had circumvent the family structure and patients recognized the significantly higher internalized (Abuddabeh, 1995; Smith, 2011). prevalence of stigma as a barrier stigma compared to white Amer- An extreme of this can be seen in (Arfken et al., 2009). The effects icans. Furthermore, they found an event reported by the interviewed of stigma can reach to the help- that the degree of internalized mental health professionals: seeking process. It was noted that stigma predicted negative mental when individuals, or members of health outcomes and modified or I2: one time we had a parent and their families, had personally amplified other forms of stigma a child coming and they didn’t

14 Scholarly Undergraduate Research Journal at Clark University | Volume III know that the other were coming, focus in on the affect, or the way States. The Iraqi refugees felt that and they had the same therapist things are coming across, or what the US healthcare system seemed but because they had different else is going on in the room and to function more as a business names and they were booked one there is literally a third person in than as a humanitarian structure. after the other, so… They didn’t the room, and they may not even In some cases, these immigrants return after that. be in the room, they may be on the had arrived from countries where phone. Umm, so it really changes healthcare treatment had cost Structural Barriers. the dynamic, and how things are very little, or nothing at all, to Language. conveyed. having to pay large amounts of The inability to speak or money in the United States. share a language with a therapist The same interviewee Individuals can also not have can understandably deter indi- also noted how difficult it was to insurance or have Medicaid viduals from seeking treatment describe some types of therapies which is not accepted by many (Aloud, 2004; Arfken et al., 2009; over the phone and the loss of healthcare professionals within Kulwiki et al., 2000; Smith, 2011; body language: their travel range, and, as such, Vermette et al., 2015). However, cannot afford treatment (Kulwiki simply getting an Arabic interpret- I1: I was going through a grounding et al., 2000; Reimann et al., 2007; er does not solve the issue. Arabic relaxation technique… and luckily Vermette et al., 2015). Even when dialects are very distinct from I had a person interpreter and…as Medicaid applications were sent one another, and if the client does he was doing it he was mimicking for renewal, sometimes the not speak the same dialect as the my movements of tightening all individual would not hear back interpreter, then not much benefit the muscles and you could tell that for months and would be left has been achieved (Vermette et the patient might not have fully unaware if they had insurance al., 2015). The community health understood the words cause it was or not (Vermette et al., 2015). organization from which the something new for her, but she was Individuals could even be in a interviewed panel of mental health like, she started tightening too, and way fined for attempting to get professionals were drawn from it just changes the dynamic. insurance, as an Iraqi woman had overcome many barriers in serviced by one of the interviewed this regard, as it had both on-call The availability of live providers was forced to pay $500 phone interpreters and three interpreters in this location a month for insurance for filling in-house interpreters. However, was low as they were spread out out an application for the state an analysis of the difficulties throughout the entire health health insurance incorrectly. that still surfaced at this location center. This meant that even can illuminate more nuanced though they had interpreters, it Informational. cracks that emerge once main was not frequently a reality with An inherent issue as to barriers are removed. A major one provider noting they had yet why some Arab-Americans do issue with language was when a to receive a live interpreter not seek formal mental health therapist received a response that regardless of how many times services is that they do not have did not match the question, they they had requested it. Furthermore, a good understanding of what were unsure if the response was there was the noted issue of the psychotherapy even is (Erickson mistranslated, misunderstood, interpreter in some cases shaming & Al-Timimi, 2001; Smith, 2011). or even if it was simply psycho- the client (Vermette et al., 2015). Even if they do know of the sis. Difficulties with the phone existence of psychotherapy, there interpreters ranged from sound Financial. can be confusion about the quality, quality of the interpreter Like many ethnic groups, distinct roles of each profession themselves, and loud noises in finances serve as a barrier for in the mental health field the background. One interviewee Arab-Americans. In a study of Iraqi (Vermette et al., 2015). These noted the dynamic shift in using refugees, Vermette and colleagues findings were mirrored in the a phone interpreter: (2015) noted the disdain some of interview conducted by the author the recent immigrants felt for the and displays the lack of awareness I1: a lot of our training is to like healthcare system in the United of what the role of therapy and

15 ARAB-AMERICAN MENTAL HEALTH DISPARITIES: Sherief Eldeeb

the role of the therapist is to some even in some cases when members which have a stronger client- Arab-Americans: of the Arab-American community focused nature. One of the wish to seek specialists, they are clinicians the author interviewed I1: I remember one particular unsure to go about how to do so noted that this clash of expectations client telling me her kids and they (Smith, 2011; Vermette et al., 2015). between client and therapist almost described to her what styles had led to “…frustration a therapist would do. And she Provider factors. [that] has led a couple of clients wouldn’t have had as good as a The most pervasive to sort off stop coming back” as definition. So I guess that if they category of issues reported within the Arab-American clients “really were seeing a therapist they would the literature revolves around the want the clinicians to lead it.” have a better idea what they are disconnect between providers and Gender is one therapist charac- here for. Arab-American patients. At the teristic that can form a barrier in very root of this issue lies three some cases. Due to the traditional I3: that mental health treatment… things: discrimination/bias, value of women’s modesty in some it doesn’t exist, it exists for people difference in expectation of Arab cultures some may find it that have very significant chronic therapy, and lack of training in difficult to reveal information to like schizophrenia, so this concept cultural and religious competence their provider in general, and this of coming to talk to somebody is specific to the community. can be amplified further if the completely foreign and they think In a qualitative study provider is male (Yosef, 2008). that you know they can just come conducted by Kulwiki and One male therapist interviewed and oh give me my pill and I’ll sleep colleagues (2000), it was noted by the author noted that this had better without understanding that that Arab-Americans expressed been reflected by his experience in we don’t prescribe medicine, or dislike at their perception of therapy, and that female therapists they’ll be asking people to take on disrespect towards their people seemed to have more “permission” the role of more of a case manager… and their culture by healthcare in regards to sensitive topics such and then we push back saying providers. This occurrence was as love. However, in rebuttal to that is somebody else’s responsibil- not a baseless phenomenon, as this point, one female therapist ity, they get very frustrated…and a review of medical records of during the same interview noted don’t come back, or come back Arab-American patients concluded that she had a client that shared with the same expectation and that health professionals had more personal details than she then the same answer…it’s not a significantly negative attitudes had expected a male Arab to do. sexy dance. towards them (Lipson, Reizian, & This is an especially important Meleis, 1987). Both patients and reminder that these cultural This is likely due to the providers noted prejudice towards revelations should be taken dearth of mental health services Arab-Americans as a salient barrier cautiously, and adapted to the within the Arab world, partially in a study conducted in Texas, individual, or else therapists run due to the tendency for not only directly from the providers, the risk of offending the patient psychologists to work in academia but also from other staff and forming another barrier. instead of as clinicians (Okasha, (Vermette et al., 2015). The needs for cultur- Karam, & Okasha, 2012). On top Arab-Americans tend ally and religiously appropriate of this, a noted issue in this com- to have a high level of respect therapies have been brought into munity is a lack of recognition of towards Western medicine and the mainstream focus after the psychological symptoms, so help health practitioners, often leading Surgeon General’s Supplement on may not be sought out as it is not to a deference of judgment to the Culture, Race, and Ethnicity for- even known what the problem practitioner who is expected mally acknowledged the existence is (Erickson & Al-Timimi, 2001; to assume an “expert role” (Cross of mental health disparities, but Aloud, 2004; Vermette et al., 2015). Cultural Health Care Program, these needs still form a barrier to Part of this issue is the lack of 1996; Gorkin et al., 1985). this day (Satcher, 2001). When distribution of health information This clashes with modern the interviewed panel of mental within the Arabic language (Ver- recommendations of more health professionals were ques- mette et al., 2015). Furthermore, humanistic-influenced therapies tioned about their training in reli-

16 Scholarly Undergraduate Research Journal at Clark University | Volume III gious and cultural sensitivity, they and dealt with in order to reduce useful due to the value system noted that it was mainly learned disparities in this community. placed around family in Arab through their own motivation to However, it must be stressed once culture. This could decrease study the topic. They clarified that again that judgment calls must family stigma from attempting to religious and cultural sensitivity be made when considering these circumvent the family structure was not taught in their classes, implementations in some cases in (Abdubbah, 1996; Smith 2011). It especially in the case of religion. order to avoid seeing patients as is also essential that once they are Most of the knowledge they “just an Arab-American,” when in therapy, extra care should be gathered about the culture and their presenting problems and taken when screening for inter- religion of Arab-Americans was goals could be unrelated. preters to prevent the client from mainly through trial-and-error being stigmatized within the with patients and conversing with Stigma. therapy room (Vermette et al., their interpreters, who formed Tying into the usage of 2015). Due attention should be a link to the community. This the biological illness concep- paid when it is known there is is troublesome as studies have tualization as a mechanism to a small Arab community in the repeatedly shown that a main decrease stigmatization, this area, as it opens up the very real barrier for Arab-Americans in illness conceptualization could possibility the client and inter- seeking treatment is this lack of a be emphasized when promoting preter may know one another. It common understanding of their educational materials in order to should also be noted that some culture (Aloud, 2004; Kulwiki et decrease stigma within the have tried experimentally testing al., 2000; Reimann et al., 2007; community as a whole (Aloud, stigma reduction activities within Smith, 2011; Vermette et al., 2015). 2004; Smith, 2011). This the Arab-American community. At the very root of this issue may implementation could also target Jaber and colleagues (2015) be a mismatch of definition of the tendency of Arab-Americans reported that a five minute stigma “culturally competency” between to prefer the medical model. reduction exercise was not useful caregivers and clients. Kulwiki Therapy settings within hospitals in decreasing stigma in a study and colleagues (2000) found that or medical settings could be of Muslim Arab-American non-Arab health professionals recommended, or referred to by adolescents, and so future defined “cultural competency” as other organizations, in order to research could be focused on treating everyone with the same work within preferences of the if different types or lengths of degree of care, whereas Arab patients and to increase the exercises could be effective. patients wished to be specifically association with the biological treated with their culture in mind. illness conceptualization, therefore Structural. Alongside this, religion can be a hopefully decreasing Language. particularly important facilitator stigmatization (Gearing et al., Language is a central in gaining access to this popula- 2012). Since Arab-Americans barrier to address. Language is a tion as some feel distanced from tend to prefer PCPs, and working substantial component of culture, therapy due to its secular nature. within the model of somatiza- and psychotherapy is especially This may be due to the spiritually tion as a way to avoid stigma, dependent on this exchange affected illness conceptualizations perhaps PCPs can utilize a more more so than perhaps any other of this population (Aloud, 2004; comprehensive mental health healing field (Bernal & Saez- Bagasara & Mackinem, 2014; battery or be made more aware Santiago, 2006). Therefore, it is Smith, 2011). of the somatization in Arab- recommended that mental health American clients to direct them treatment centers are allocated ADDRESSING BARRIERS FOR towards therapy (Aloud, 2004; their own Arabic interpreters FORMAL MENTAL HEALTH Al-Krenawi & Graham, 2004; that speak the relevant dialect SERVICES Hotopf et al., 2001; Vermette et (Aloud, 2004; Reimann et al., It is relatively simple al., 2015). If one was able to bring 2008; Vermette et al., 2015). Due to merely note barriers, but the Arab-Americans into therapy, in- to the noted importance of affect work must not end there. These cluding more notions of family or and emotional connection by the variables must be understood family therapy may also be more mental health providers inter-

17 ARAB-AMERICAN MENTAL HEALTH DISPARITIES: Sherief Eldeeb

viewed, it is important to make 2000; Reimann et al., 2007; the possibility of language gaps in all efforts to have this interpreter Vermette et al., 2015). This may informational pamphlets. There- be present in therapy. However, take the form of need-based pre- fore, care should be taken in it would be naïve to expect this paid bus passes, or reimbursal if offering information for mental without taking financial consid- there are no buses within reason- illness as well as for the health- erations into account. If hiring able range of the patient. care system. Providing informa- translators is not a viable option, tion in the relevant dialects of the or if efforts are being made to Informational. community applying to Medicaid circumvent issues in affect during Psychoeducation is ensures Arab-Americans have therapy, an emphasis on training key for this population as it is a working knowledge of these and hiring Arabic-speaking pro- a noted issue that many do not things. Refugee and immigrant fessionals could be a useful inter- have a good understanding of populations should be offered vention. Furthermore, although mental illness, of what roles the the possibility to take a course some authors have argued ethnic different mental health profes- on the healthcare system, roles and linguistic matching is neces- sions play, or of what therapy is of professionals, and applying sary, it seems realistic to expect (Erickson & Al-Timimi, 2001; to Medicaid to address this gap therapists to at least have cultural Goforth, Pham, Chun, Castro- (Vermette et al., 2015). and religious knowledge of the Olivo, & Yosai, 2016; Reimann et population in order to correctly al., 2007; Smith, 2011). Another Provider factors. serve them (Aloud, 2004). key informational barrier in this In order to address the population is how the medical perception, and reality, that some Financial. system works and how to apply for healthcare providers are preju- As a country, much must funding such as Medicaid or other diced against Arab-Americans, be done in order to make the sources of insurance (Erickson & the general public and physi- landscape for mental healthcare Al-Timimi, 2001; Vermette et al. cians should learn more about more affordable. Greater care 2015). One possible intervention the realities of Arab culture and must be taken to return Medicaid to explore is allocating more religion to decrease stereotypes, applications within a specific time funding for the assistance of case misconceptions, and discrimination frame for individuals to know workers or community outreach (Erickson & Al-Timimi, 2001; if they are insured or not. This initiatives. This is supported by Goforth, Pham, Chun, Castro- is especially relevant to Arab- the fact that Stein and colleagues Olivo, & Yosai, 2016; Kulwiki et American populations, such as (2014) reported that community al., 2000; Lipson et al., 1987). This refugees or recent immigrants, outreach centers noticed greater also extends to staff in general, who may be unfamiliar with rates of engagement when there such as receptionists, as all are the medical system in the United was dedicated staff to outreach. associated with the healthcare States due to sharp contrasts In order to mitigate stigma and system (Smith, 2011; Vermette et in comparison to the medical increase psychoeducation in the al., 2015). Another approach is if systems of their home countries community, a local mental health therapy is not directly accessible (Vermette et al., 2015). Community provider proposed that there to some is to bring the therapy to health centers, such as the one should be: them. Since some patients do not where the author conducted an recognize mental illness symptoms interview, can be very useful I2: more group activities that are or simply prefer religious healing, resources for those that do not not necessarily direct therapy, perhaps religious leaders can be have insurance. Efforts must be but more socializing and provide used as a resource by teaching taken to better publicize and fund more psychoeducation, so that them basic mental health awareness these resources as a safety net for our clients who don’t understand techniques and asking them if those that are under-insured or what therapy is, what psychology they would be open to referring not insured at all. Ease of trans- is what mental health is, can get a clients to therapy (Aloud, 2004). portation to these centers is also better understanding The integration of mental health essential to circumvent the Language is essential services with local religious barrier of travel (Kulwiki et al., even outside of therapy due to centers could be useful in teaching

18 Scholarly Undergraduate Research Journal at Clark University | Volume III clients what therapy is and clearing misconceptions about it from within the community. Due to the lack of en- forced current education, as noted in the interview conducted by the author, it would be wise to begin integrating more in-depth learning about the culture and religions of the ethnic groups therapists are working with. Part of cultural competency training will need to place an emphasis on the definition of being treated differently because of the inclusion of their culture, and not just receiving the same therapy as everyone else (Kulwiki et al., 2000). In some cases, part of this cultural adaptation can even be the therapist simply adopting more of an “expert role” than a client-centered approach (Erick- son & Al-Timimi, 2001). Modern efforts on tailoring therapies to include functions of religion and culture should be continued in order to assist breaching the barriers noted in this review (for an example of an adapted therapy, see Hinton, Rivera, Hofmann, Barlow, & Otto, 2012). Flexibility may also need to be advocated on the side of the therapist if the client does not recognize or understand the differences in roles of mental health professionals. Furthermore, in some cases with this community, therapists must become more comfortable with some roles of a case worker in order to adequately address some very real needs of the community (Kim & Cardemil, 2011). Hopefully, if these efforts are met, current mental health disparities in the Arab-American population will decrease and more research will be conducted on this underserved group in the Western world.

19 ARAB-AMERICAN MENTAL HEALTH DISPARITIES: Sherief Eldeeb

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FACULTY SPONSOR: Esteban Cardemil, Ph.D.

ACKNOWLEDGEMENTS I am extremely grateful for the assistance given by Dr. Esteban Cardemil for his insightful comments during the development and review of this work as well as his assistance in setting up the interview included in this work. Furthermore, I am grateful to the panel of mental health professionals that were interviewed and for the assistance of Cindy Mohnblatt Bronstein in conducting the interview. Finally, I would like to express my appreciation to my friends, family, and girlfriend for their endless support.

AUTHOR BIOGRAPHY | Sherief Eldeeb Sherief Eldeeb is a Psychology major and Biology minor at Clark University. Sherief has research interests spanning mental health disparities, the development and treatment of anxiety and autism spectrum disorders, the mind-body connection, and the efficacy of mindfulness interventions. Sherief is currently combining his research interests by examining the efficacy of mindfulness interventions with victims of trauma using psychological and psychophysiological measures as part of his Honors Thesis. After graduation in 2018, Sherief plans to expand on his research expertise before pursuing a graduate degree in clinical psychology.