Running head: COUNS LEBANESE AMERICANS 1

Counseling Lebanese Americans: A Culturally Sensitive Approach

Hafsa Ahmed, Colin Freeland, and Sara Moe

Mercer University

COUNS LEBANESE AMERICANS 2

Counseling Lebanese Americans: A Culturally Sensitive Approach

Cultural identity has a profound impact on individuals’ mental and physical health, influencing feelings of belonging and security and contributing to a sense of well-being within society. For this reason, a growing body of research suggests that developing cultural competence is a salient task for counselors wishing to achieve effectiveness across a diversity of clients (Abudabbeh & Hays, 2006; Sue, Sue, Neville, & Smith, 2019). Within the Lebanese

American population, culture, religion, and sociohistorical context significantly impact attitudes toward seeking counseling, common therapeutic issues, and prominent barriers to treatment.

Through incorporating this cultural knowledge into theory and practice, counselors can develop and implement sensitive, appropriate skills and intervention strategies.

Historical Background

Large-scale Lebanese immigration to the United States began in the late 19th century and can be divided into three distinct waves. The first wave, lasting from the late 1800s to World

War I, consisted predominantly of poor, uneducated Christians escaping economic hardship and religious persecution under the Ottoman Empire (Nassar-McMillan & Hakim-Larson, 2003).

This group was initially denied naturalization and citizenship on the basis of being Asian and therefore not a part of the White race (Suleiman, 1999). The status of Lebanese people in the

United States remained tenuous until after World War II, when they were officially classified as

White and granted citizenship under the 1940 Nationality Act. Around this time, a second influx of Lebanese people entered America. This group contained large numbers of well-off, highly educated Muslim professionals (Abudabbeh & Hays, 2006). A third wave, beginning in 1966, occurred as a direct result of the economic crisis and political instability resulting from the

Lebanese civil war (Suleiman, 1999). This group was more heterogeneous than earlier waves of COUNS LEBANESE AMERICANS 3 immigrants, containing both Christians and Muslims and a mix of students, professionals, and refugees. In contrast to early immigrants who fought to be viewed as White in order to retain their right to citizenship, Lebanese people arriving in recent decades were more likely to maintain their ethnic identity and cultural traditions (Abudabbeh & Hays, 2006).

Today, more people of Lebanese decent live outside of Lebanon than within. According to the U.S. Census, there are an estimated 1.9 million Arab Americans residing in the United

States, with Lebanese people accounting for 56% of that population (Sue, Sue, Neville, & Smith,

2019). Due to the absence of a category for Arabs on the U.S. Census short form, a significant discrepancy exists between this number and the Arab American Institute’s adjusted population estimate of 3.6 million (Arab American Institute, 2012).

Racial and Ethnic Identity

In order to fully understand Lebanese Americans’ racial identity construction, it is first necessary to examine the ways in which Arabs in America have historically been racially identified. The U.S. stance on the earliest Arab immigrants was inconsistent, categorizing those of Middle Eastern decent as “Asians, ‘other Asians,’ Turks from Asia, Caucasian, ‘White,’

Black, or ‘colored’” (Suleiman, 1999, p. 7). Assimilation and citizenship training in this group was widely advocated with the goal of affirming their whiteness and justifying their eligibility for citizenship, resulting in a population that was largely indistinguishable from the dominant culture (Suleiman, 1999). By the 1960s, although Arab Americans were legally considered

White, their experience more closely aligned with that of people of color. America’s Pro-Israel stance during the 1967 Arab-Israel war increased negative media coverage of Middle Easterners, resulting in increased stereotyping and social and political marginalization (Naber, 2000).

Lebanese Americans’ technical White identity remains at odds with their lived experience, COUNS LEBANESE AMERICANS 4 affording them the “double burden of being excluded from the full scope of whiteness and from mainstream recognition as people of color” (Cainkar, 2006). In recent years, Arab American civil rights groups have lobbied for a new classification, “Middle East or North Africa

(MENA),” to be included on the 2020 Census, officially reclassifying this population as a minority and therefore granting them access to government-based grants and affirmative action in higher education. Further complicating Lebanese Americans’ ethnic identity is the fact that many Lebanese Christians prefer to identify themselves as descendants of Phoenicians rather than Arabs (Haboush, 2005).

Despite this shared racial history, Lebanese Americans are heterogeneous in terms of religion, language, and degree of acculturation. Education appears to be important for Arab

Americans, with 49% holding a bachelor’s degree and 20% holding a post-graduate degree.

Lebanese Americans have a higher homeownership rate (71.6% versus 65.1%) and household income ($67,264 versus $49,445) than the national median (U.S. Census Bureau, 2013).

Although the majority of Lebanese Americans speak English, they may also speak Arabic,

French, or Armenian in the home.

Family Structure and Gender Roles

Lebanese Americans tend to be collectivist and group-oriented, with a strong emphasis on family as a major source of one’s identity. Harmony, integrity, and interdependence are emphasized, and obedience and conformity are valued over competition and self-fulfillment

(Suleiman, 1999). Families typically have a multigenerational, patriarchal structure characterized by authoritarian parenting and fixed gender roles. In contrast to their western peers who are encouraged to separate from parents and develop independence, Lebanese American children are expected to maintain close relationships with their parents and rely on the family COUNS LEBANESE AMERICANS 5 unit for problem-solving (Haboush, 2005). Decisions regarding dress, education, career, and child-rearing are often made collectively, and romantic partners may be chosen by an individual’s family. Maintaining family honor is a salient concern, and Lebanese Americans often are very private, discussing personal issues only within the family or with very close friends (Suleiman, 1999). For this reason, they may be less likely to pursue counseling or psychiatric care.

Although Lebanese Americans have moved toward a more egalitarian view of women, honor and modesty are still utilized as controlling issues, especially for adolescent girls

(Suleiman, 1999). Shame and guilt are often used to motivate morality and restrict premarital sexual activity in this group. Boys, on the other hand, are often allowed to embody more of the social characteristics of American society, such as freedom to go out with friends and even date

(Suleiman, 1999). This differential treatment extends to some degree into adulthood, and

Lebanese American men are generally accorded more sexual freedom than their female counterparts (Haboush, 2005). Despite restrictions placed on females, Lebanese American women hold significant power in the family due to their role in maintaining unity and cohesion

(Haboush, 2005). Girls are also encouraged to pursue education and achieve at high levels.

Divorce is generally frowned upon in the Lebanese American community. Many Lebanese

Christians are forbidden by their religion to divorce; Muslims may be permitted to do so with certain legal stipulations (Abudabbeh, 2005).

Religiosity

Religion is a major underpinning of ethnic identity for most Lebanese American individuals, functioning not only as a religious code but also dictating cultural, political, and familial norms and beliefs (Suleiman, 1999). The vast majority of Lebanese Americans are COUNS LEBANESE AMERICANS 6

Christian or Muslim, with a smaller percentage identifying as Druze. Lebanese Christians belong predominantly to Eastern Rite churches, including Maronite, Eastern Orthodox, and

Melkite/Greek Orthodox. The main branches of Islam practiced by Lebanese Muslims are Sunni and Shiite.

Within Islam, the Qur’an is the central religious text, providing guidance on social and family issues, economics, politics, and sexuality (Sue, Sue, Neville, & Smith, 2019). Lebanese

Muslims are expected to conduct themselves according to the “Five Pillars of Islam,” tenets that oblige them to declare their faith to God, engage in ritual prayer five times a day, fast annually during daylight hours in the month of Ramadan, give to the poor, and undertake a pilgrimage to

Mecca (Abudabbeh, 2005). Some Muslim women wear traditional clothing in the form of a hijab or head covering because of Islam’s emphasis on modesty, a custom subject to much scholarly debate in terms of its impact on oppression and women’s rights (Abudabbeh, 2005). In both Muslim and Christian Lebanese American families, the fear of God is often used to prompt culturally appropriate and respectful behavior (Suleiman, 1999).

Due to their strained historical relations during the Crusades and Lebanese civil war, a high amount of tension still exists between Lebanese Muslims and Christians, rendering intermarriage between groups unacceptable (Abudabbeh, 2005). Marriage between Arab

Muslims and non-Arab Muslims is also discouraged.

Specific Challenges

Stereotyping and Racism

While Lebanese Americans have been subject to stereotyping and racism since their arrival in America in the 19th century, prejudice and discrimination have been especially pronounced following the terrorist attacks of September 11, 2001. Since that time, frequent COUNS LEBANESE AMERICANS 7 media misrepresentation and vilification have ignited a pervasive anti-Arab sentiment in the

United States, subjecting Lebanese Americans to increased scrutiny, profiling, and hate crimes

(Abudabbeh, 2005). On September 12, hundreds of whites surrounded a large, predominantly

Arab mosque in Chicago, wielding weapons and shouting, “kill the Arabs” (Cainkar, 2002). In the following nine weeks, 700 violent incidents were reported by Arab Americans or those perceived to be of Middle Eastern decent (American-Arab Anti-Discrimination Committee,

2003).

Although there has since been a decrease in violence and hate crimes, stereotyping and discrimination are still salient concerns in this population. On the 14th anniversary of the attacks, more than 50,000 tweets were sent out using the hashtag #AfterSeptember11 describing experiences of post-9/11 era racism and intolerance. Additionally, many Arab Americans feel that governmental initiatives such as the Patriot Act and Executive Order 13769 (commonly known as “The Muslim Ban”) have legitimized discrimination, increasing marginalization as well as fears of deportation and detention (Abudabbeh, 2005).

Acculturation Conflicts

Lebanese Americans encounter abundant stressors as they adapt to life in the United

States. Language barriers, economic and employment difficulties, and racism and stereotyping all contribute to the acculturative stress felt in this population. Those entering the country as refugees face particularly high levels of hardship as they often arrive with traumatic experiences that impact their psychological adjustment (Abudabbeh, 2005).

Acculturation is a complex, multigenerational process, and Lebanese Americans’ level of acculturation and assimilation varies widely. For young people, inconsistencies in the private sphere of family and home and the public sphere of school and community contribute to unique COUNS LEBANESE AMERICANS 8 challenges (Haboush, 2005). Arab American women appear to have more difficulty defining an acceptable or comfortable bicultural identity, perhaps because of the clash between traditionally- defined gender roles and American views on modesty and sexuality (Suleiman, 1999). Muslim women, who are often subject to higher levels of ethnic visibility due to their traditional garments and prayer practices, may be particularly prone to acculturation challenges. For many

Lebanese Americans, the simultaneous desire to feel pride in their cultural heritage and avoid discrimination has complicated the formation of an integrated identity.

Literature Review

Estimates of up to 17% of the population in Lebanon suffer from one or more mental health problem were reported in a large epidemiological study conducted by the World Health

Organization (Lee, 2011). Other results from this survey revealed that nearly half of the same population had experienced a distressing event related to war; with this data being collected prior to Lebanon’s 2006 war. Other studies (Karam, Mneimneh, Fayyad, Karam, Nasser, Chatterji, &

Kessler, 2008) have demonstrated that as many as one in every four Lebanese have experienced at least one, and in some case more than one, DSM-IV disorder over their lifetime. It has been reported that only approximately half of Lebanese individuals that suffer from a mood disorder have ever received treatment and frequencies of receiving treatment for other disorders were much lower. Karam, et al. (2008) also found that “exposure to war-related events increased the risk of developing an anxiety, mood, or impulse-control disorder by about 6-fold, 3-fold, and 13- fold, respectively” (p. e61). Considering the vast social, political, cultural, and political psychosocial stressors that many refugees, immigrants and even U.S. born Arab-Americans often face, this cohort may be at elevated risk of experiencing adverse mental health outcomes in addition to being less likely to seek traditional mental health treatment services. Pre-migration COUNS LEBANESE AMERICANS 9 stressors often include war, political conflict, persecution based on religion, race, ethnicity, gender, sexual orientation or other social group membership, and economic stress (Pampati,

Alattar, Cordoba, Tariq, & De Leon, 2018). Further, post-migration stressors often include acculturative stress associated with resettlement, language barriers, social isolation, xenophobia,

Islamophobia, discrimination, and difficulty accessing secure employment, housing and transportation (Pampati et al., 2018). Anti-Arab sentiment is correlated with heightened prevalence of depression and general distress in Arab American populations, further, pre- migration trauma is positively correlated with prevalence of depression and PTSD (Abuelezam,

El-Sayed, & Galea, 2018). The same study revealed that those who endorsed elevated rates of

PTSD and depression as a result of trauma occurring before migration that engaged in brief narrative exposure therapy, experienced a greater level of well-being and post traumatic growth, as well as a reduction in depressive symptoms indicating some empirically supported efficacy for this modality for these issues in this population (Abuelezam, El-Sayed, & Galea, 2018).

Evidence has also alluded to the presence of barriers to therapeutic work for Arab-Americans.

There has been a dearth of systematic information available regarding the needs of Arab

Americans as related to mental health. The small number of studies so far suggest that Arab

Americans experience greater mental health challenges as compared to majority non-Hispanic

Whites. A published estimate by Amer and Hovey (2011) suggests that up to 50% are reporting depression scores that meet clinical criteria in addition to approximately one-fourth reporting moderate to severe anxiety.

Prevalence and Disparities

Arab Americans are often less prominently studied as a group within the current literature on disparities, a fact that is worrisome for the current 3.6 million (Arab American Institute, 2012) COUNS LEBANESE AMERICANS 10

Arab Americans in the U.S. today. The necessity of culturally and religiously adapted or oriented modalities was acknowledged after the Surgeon General’s Supplement on Culture,

Race, and Ethnicity formally acknowledged the existence of mental health disparities, but these needs still form a barrier today. Overall, research on the mental health needs and outcomes for this population has increased some since September 11th however, stigmatization of this population is increasing alongside it (Abuelezam, El-Sayed, & Galea, 2018). The overall prevalence rates of emotional disorders and other mental health related outcomes for this population remains somewhat elusive (Abuelezam, El-Sayed, & Galea, 2018). The current literature has fallen short in assessing the true prevalence of mental health outcomes in this population, which is often referred to as the “invisible minority.” According to Amer and Hovey

(2011), “people of Arab descent are often categorized as ‘White’ or ‘Caucasian’ by the American government, thus making it unfeasible to extract group-specific data from public health databases” (p. 410). Efforts to obtain accurate estimates of the burdensome psychological problems encountered by this population are further thwarted by methodological challenges which include a difficulty in identifying Arab populations, cultural stigmas surrounding help- seeking and a paucity of multiculturally competent services directed at this population

(Abuelezam, El-Sayed, & Galea, 2018).

One study (Jaber, Farroukh, Ismail, Sobh, Hammad, & Dalack, 2014) sought to measure depression and stigma towards depression and treatment in a sample of adolescent Arab

Americans. Using the Patient Health Questionnaire-9 (PHQ-9) it was shown that 14% of adolescents in the study endorsed moderate to severe depression, these rates indicate a need not only to increase education, screening and awareness within the Arab American youth but also availability and access to services for mental health. In the same study with regards to mental COUNS LEBANESE AMERICANS 11 health help-seeking, 13% of adolescents reported previously being in contact with a mental health professional about their issue and of those who did not or were unsure, 35% said they would not ever consider speaking with someone in a professional capacity about these types of challenges (Jaber et al., 2014). Moreover, a recent study demonstrated that Arab Americans are among the least likely to seek out a mental health professional for issues related to depression, however, they are among the most likely to seek this help from a primary care physician

(Dotinga, 2017).

Help Seeking Preferences and Behaviors

A more in depth and comprehensive understanding of how Arab Americans actually conceptualize mental health problems can help us to gain further insight into how they choose to seek help and what routes they may undertake to do so; prominent conceptualizations include biological, religious, supernatural, and environmental models (Eldeeb, 2017). Biological models appear to be the most dominant, but it was also found that religious models are also prevalent in this population (Bagasara & Mackinem, 2014). Likely related to this biologically dominant view are the frequently reported somatization and conversion disorders by many members of the Arab population. In a survey of help-seeking preferences and attitudes for mental health disorders,

Aloud (2009) found that Arab Americans reported that 33% preferred medical doctors, 22% preferred family, 19% preferred approaching an Imam or Sheikh, 11% preferred formal mental health services, and 6% stated they would not seek help at all. These findings implicate that more extensive training of primary care physicians in identifying clinically significant symptoms and effective and appropriate didactic intervention coupled with service coordination and referral may need to begin in the medical community rather than community organizations or traditional mental health services. COUNS LEBANESE AMERICANS 12

Prominent Barriers to Treatment

As cited previously, stigma continues to be a barrier to treatment in this population.

Stigma is one of the most often cited themes in the literature as a barrier for this population.

Aloud (2009) found that, without regards to education level, it was the most reported barrier among Arab Americans. Some focus group discussions have illuminated individual reports of fear that others would perceive them as “weak” or that they “had nothing better to do” if they sought therapy. Of note, the participants in this study clarified that this was not associated with

Islam in particular but was in fact related to cultural stigma within the Arab community (Smith,

2009). Both Smith (2009) and Aloud (2009) have noted that when individuals, or members of their families, had personal experience with some form of mental illness, they were both more likely to relate it to biological etiology or model and to seek treatment from a primary care source. Other barriers to treatment include language, financial and informational. The inability to speak or share a language with a therapist often and rightfully contributes to an aversion to seeking help. Further fortifying this barrier is the idea that simply getting an Arabic interpreter will overcome this. Most dialects are very distinct from each other, therefore if the interpreter and client speak different dialects then the potential benefits will be lost (Eldeeb, 2017). Like many ethnic groups, finances also serve as a barrier for Arab Americans. In some cases, these immigrants have arrived from countries where healthcare treatment had little or no cost, compared to the sometime exorbitant prices of healthcare in the U.S. which often leads to disdain for the American healthcare system (Eldeeb, 2017). Another inherent issue as to why some Arab

Americans do not seek mental health services is that many do not fully understand what the practice of counseling really is (Smith, 2011). In some cases, even if they are familiar with the existence of psychotherapy, there can still exist great confusion over the different roles within COUNS LEBANESE AMERICANS 13 the field, which is likely attributable to the general lack of these services in the Arab world and the tendency for psychologists to work in academia rather than practicing in the more clinically driven arena (Smith, 2011). Finally, the most pervasive group of challenges shown in the current literature centers around the apparent disconnect between clinicians and members of the Arab

American populations. According to Eldeeb (2017) “at the root of this issue lies three challenges: discrimination and bias, difference in the expectation of therapy, and lack of training in cultural and religious competence specific to this community” (p. 16). This speaks to the need for emphasis on cultural competency training in westernized education systems. Moreover, a fact that conflicts with the modern and westernized view of client-centered humanistic modalities, many Arab Americans may prefer to engage with a clinician that they perceived to be in the “expert role” (Eldeeb, 2017). Gender should also be taken into account as an existing barrier or the basis on which a new barrier to meaningful therapeutic work may be built. Taken together, these cultural considerations should be reviewed carefully, and fit to each individual, if they are not then therapists are taking the risk of potentially offending the client, forming another barrier, contributing to iatrogenic effects, early termination of services or contribution to reluctance of future help-seeking behaviors.

While a wide breadth of outcome data does not currently exist and researchers are still working to uncover the true incidence and prevalence of mental health disorders within Arab

American populations, it is apparent from the existing literature base that inordinate levels of depression, anxiety, intergenerational and acculturative stress are significant. Pre-migration trauma related to war exposure, among other things, or intergenerational trauma in first generation U.S. born Arab Americans appears to be of relevance as well. There has been some evidence to support the use of brief narrative exposure therapy with this specific presenting COUNS LEBANESE AMERICANS 14 problem, however more work is needed to demonstrate the efficacy of culturally adapted modalities to assuage mood and anxiety symptomology which appear prevalent in this population. It appears, as evidenced by many Arab American cultural preferences to seek help, at least initially, from a primary care physician, intervention may be effectively originated there and consist mostly of referral and didactic strategy. In the following section, we will attempt to offer culturally adapted and relevant strategies to address the ever evolving and multi-layered needs of this population.

Counseling Lebanese Americans

Cross-cultural research (Sue, Sue, Neville, & Smith, 2019) suggests that counselor awareness, knowledge, and skills (i.e., multicultural competence), empathy, and self-efficacy are salient characteristics for working with culturally diverse clients. Knowing this, counselors working with Lebanese Americans would be prudent to attend to several variables. Firstly, it is important for counselors to educate themselves on both the sociohistorical context and available research regarding this population. Additionally, mental health professionals in the United States are exposed to prevalent negative stereotypes associated with Arab Americans and therefore need to examine their own feelings and attitudes towards this population. This self-exploration can serve as a gateway for counselors to begin to recognize how any potential biases may impact their multicultural competence, empathy, and efficacy with Arab Americans (Constantine &

Ladany, 2000). Counseling may also be greatly enhanced by choosing modalities and skills that are consistent with Lebanese Americans’ lived experience and racial, ethnic, and cultural identity. A multidimensional approach that balances the use of universal and culture-specific strategies should be considered.

Theoretical orientation is an essential part of a counselor’s professional identity, COUNS LEBANESE AMERICANS 15 informing how they conceptualize clients, therapeutic goals, and interventions. A comprehensive understanding of many theories allows a counselor to develop an orientation congruent to their personality and strengths, and affords them flexibility to utilize skills and interventions compatible with the distinctive needs and characteristics of each client. In considering Lebanese Americans, prominent issues and challenges appear to be depression,

PTSD, anxiety, pre-migration trauma, and intergenerational and acculturative stress. Mental health professionals should consider utilizing a therapy that considers the nuclear family and is reflective of collectivistic values. Counseling that is concrete, structured, and supported by clear empirical research is likely to be effective given this population’s high level of respect toward western medicine and emphasis on authority figures. Lebanese Americans seeking counseling may initially present with a desire for short-term solutions and concrete advice. The concept of catharsis and the curative process of expressing one’s feelings are considered a westernized concept and often thought of as shameful. Further, Arab culture does not emphasize talking about feelings outside of the family or community, and such disclosures are often characterized as disloyal or weak (Al Krenawi & Graham, 2000). In counseling Lebanese Americans with a high degree of religiosity, it may be beneficial if the clinician integrates spirituality or traditional indigenous healing practices into sessions. By incorporating the beliefs of the client, the therapist communicates respect for their cultural values, strengthening the therapeutic alliance and increasing trust (Al Krenawi, 2005).

Several studies have shown that cognitive-behavioral approaches such as reality therapy may be the most appropriate with this population because people from collectivistic cultures tend to revere authority and prefer active, directive treatment (Al Krenawi & Graham, 2000).

Therapists may benefit from implementing an eclectic approach of psychoeducation, cognitive- COUNS LEBANESE AMERICANS 16 behavioral interventions (Al Krenawi & Graham, 2000), and narrative-based counseling to show respect and value for cultural conceptualizations of mental illness (Ahmed & Reddy, 2007).

Integrating a narrative approach fosters collaboration, empowers the client to use their own language in discussing issues and treatment, and externalizes problems of oppression and marginalization (Corey, 2017).

Reality Therapy

Reality therapy was developed by William Glasser in 1965 and is grounded in cognitive and behavioral theory and interventions. This therapy focuses on solving present problems, improving relationships, and developing the skills to make better choices in order to achieve goals. Glasser did not believe that clients should be labeled with a diagnosis. From his perspective, diagnoses are descriptions of the behaviors people choose in their attempt to deal with the pain and frustration that is endemic to their unsatisfying present relationships (Haskins

& Appling, 2017). Central to reality therapy are the five basic needs (survival, freedom, power, fun, and love/belonging) that humans attempt to satisfy through their behavioral choices. Reality therapy is based on choice theory, which posits that almost all of human behavior is chosen and that every individual is in control of their behavior. Reality therapists seek to answer the question, “How can one learn to live a free and authentic life, while also getting along with people whom they need?” (Corey, 2017). Through the therapeutic process, clients learn how to choose effective behaviors to achieve their relational needs and improve relationships with the people they need and want in their lives (Haskins and Appling, 2017). As clients become empowered to choose and control their own behavior, they tend to let go of previously developed maladaptive behavior and inappropriate coping skills (Corey, 2017).

Reality therapy’s focus on problem-solving can be effective for a variety of mental health COUNS LEBANESE AMERICANS 17 disorders such as depression, anxiety, addiction, eating disorders and crisis interventions

(Khaleghi, Amiri, & Taheri, 2017). Therapists practicing reality therapy instill a sense of hope in clients, facilitating a feeling that change is possible. The therapist functions as an advocate for the client throughout the therapeutic process, aiding the establishment of a strong therapeutic alliance and a trusting, understanding, and supportive environment. This supportive environment allows clients to feel free to try new behaviors, challenge their thought processes, and express themselves authentically without fear of judgment and failure. Counselor goals should include creating a safe space for the client and being free of judgment (Corey, 2017).

A key technique used in reality therapy is the WDEP system. This system assists clients in clarifying their wants, examining what they are doing to achieve those wants, evaluating their behavior, and developing a plan for improvement. The role of the counselor is to facilitate the undiscovered potential of the client and increase self-awareness through directive questioning and dialogue. As clients become more aware of the choices they make in their lives and how these choices are efficient or inefficient in achieving goals, they begin to feel more responsible and empowered in their lives.

Reality therapy is versatile, concrete, short-term, and present-centered, making it a good choice for counseling with Lebanese Americans who desire a directive, solution-focused approach. Lebanese Americans may benefit from this form of therapy as it allows them to take a proactive approach to their issues, feeling more responsible and empowered, knowing they are the ones making the direct change in their lives. The clear concepts of the WDEP system make it quick to understand, learn and implement with clients who prefer counseling that is more explanatory and instructional in nature. Additionally, reality therapy is collaborative in nature, allowing diverse clients to work with the counselor to form a plan that is consistent with their COUNS LEBANESE AMERICANS 18 cultural values (Corey, 2017).

Narrative Approach

The narrative approach to counseling grew out of the postmodern and constructivist movements of the 1950s, and focuses on the themes, language, stories, and social context of the client as a tool to subjective construction of meaning and identity (Corey, 2017). Narrative approaches recognize the client as the main character in the life story, and seek to encourage personal agency through the exploration of past stories and active construction of new ones.

Additionally, narrative therapy strives to separate the person from their problem, using externalizing conversations to counteract messages of oppression and marginalization.

Counselors use questions as a way to engage and facilitate their client’s exploration, listening not only for salient themes and language but also to identify the client’s strengths and resources.

This form of therapy assists clients in mapping what influence a certain problem has had on their lives, separating themselves from the maladaptive stories they have internalized and creating a space for an alternative narrative (Corey, 2017). Through this process, individuals are able to recognize skills and techniques they already have and utilize those skills in making life changes.

Problems are manufactured in social, cultural, and political contexts. Stories are shaped by how a person sees, feels, and acts on their own and through how they interact with others around them. By acknowledging that individuals’ stories are shaped by complexities of life in a diverse world, the narrative approach embraces multiculturalism and phenomenology.

Practitioners of narrative therapy believe telling one’s story is a form of action toward change.

The process of narrative therapy might include techniques such as helping clients objectify their problems, framing those problems within a larger sociocultural context, and assisting clients in making room for other stories. COUNS LEBANESE AMERICANS 19

The goals of narrative therapy do not seek to change the person as a whole in therapy, it instead aims to change the effects of a problem that is harming the person. Counseling sessions aim to create space between a person and any problems they discussed in their stories, whether it be depression, anxiety, or posttraumatic stress. To achieve these goals, the counselor and client examine early memories, assumptions, and themes, facilitating an awareness of the ways in which the past affects the present, and ultimately empowering the client to make more insightful and holistic decisions about the future.

Narrative therapy’s premise that problems reside within social, cultural, political, and relational contexts rather than within the individual makes it congruent with the philosophy of multiculturalism. Emphasis within this approach on gender, ethnicity, race, sexual orientation, social class, and spirituality as therapeutic issues allows the counselor to become aware of the client’s intersecting identities and understand the ways in which oppression may have negatively influenced their life. Lebanese Americans facing acculturation challenges may appreciate the emphasis on multiple realities, and the notion that these realities are constructed from cultural discourse (Corey, 2017). Taking a narrative approach allows individuals to interpret events such as war and migration-related trauma contextually, inclusive of social, cultural, and spiritual factors.

Lessons Learned

After reviewing the current literature and considering culturally adapted modalities of treatment the group has distilled several important lessons. Of note, cultural disparities in mental health services and culturally adapted treatments for this diverse population are severely lacking.

The group believes that as a result of this population being classified as “the invisible minority” it has greatly impacted the academic community in studying the increasing population that has COUNS LEBANESE AMERICANS 20 been reviewed here. As a result of this academic undertaking, the group has gained a more comprehensive knowledge base relevant to this specific cohort as to potentially modify currently accepted best practice psychotherapeutic approaches for clinical efficacy with this population.

Group members have further identified similarities and differences within their own cultures, bringing awareness to the depth and extent of ethnocentric monoculturalism pervasive in dominant culture. The group understands that specializing in one theoretical orientation will not suffice when it comes to clients that possess intersecting identities. Instead, it would be beneficial for the group to become well versed with the multiple theoretical orientations in order to best help the future clientele the group will have. The group has collectively learned that advocacy for the Lebanese Americans is strongly needed in the community to help this population gain an understanding on mental health disorders and issues and offer resources to this population for multicultural and competent mental health providers.

Conclusions

The complexity of the presenting problems within this population remains cloaked in a lack of true understanding. Cursory evidence shows that this population is inordinately impacted by elevated rates of affective and anxiety disorders, acculturative stress, intergenerational trauma, and a wide range of other psychosocial stressors. Of additional consideration is the manner in which these individuals arrived in the U.S. There have been multiple “waves” of arrivals from Lebanon into the United States, each with unique and complex stressors. Cultural and gender norms within these cohorts should be considered in working therapeutically with this population. It appears that a trauma-informed, highly directive approach, which incorporates principles of cognitive behavioral, narrative, and reality therapies to address the needs of this specialized population will be efficacious. Education on the benefits of services, culturally COUNS LEBANESE AMERICANS 21 informed services, and stigma reduction strategies should also be aligned with service delivery within the Lebanese American community. Generational and gender considerations, to include acculturative stress or generational and gender conflict are of importance in therapeutic work with this population, as well as level of acculturation of individual clients. What is more apparent is the need for further research into the prevalence and phenomenological experience of these stressors for Arab Americans. Future research, therefore, must aim to not only accurately represent these concerns but also to test the efficacy of culturally adapted modalities with their unique challenges. COUNS LEBANESE AMERICANS 22

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COUNS LEBANESE AMERICANS 26

Appendix

Diversity Workshop: Understanding and appreciating cultural similarities and differences

of Lebanese Americans

8-5pm

This workshop aims to build self-awareness to potential feelings, attitudes, biases and negative stereotypes experienced by the Arab American population, and more specifically

Lebanese Americans. This workshop also aims to bring awareness and understanding to the shared experiences of Lebanese Americans. The purpose of this workshop is to raise individual’s intrapersonal emotional awareness while honoring cultural differences. The workshop will include several activities that will question the participants’ understanding and sensitivity to differences in cultural diversity as well as the impact their behavior may have on others and to value diversity as a strength. The workshop will help facilitate meaningful discussion about mental health and provide resources for individuals seeking further support.

Workshop Itinerary:

- Introduction and Icebreaker Pass the Ball Activity

- Pretest questionnaire about Lebanese Americans’ mental health awareness

- Lecture and discussion about Lebanese Americans’ lived emotional experience

- Group activities and exercises

- Break for lunch and refreshments

- Group discussion about activities and exercises

- Posttest questionnaire about Lebanese Americans’ mental health awareness

- Final discussions, thoughts and goodbyes

COUNS LEBANESE AMERICANS 27

Some Activities:

Name: Pass the Ball

Topic for activity: Getting to Know Each Other

Goals: To integrate the group in an icebreaker activity that introduces members and allows the member to share personal information about themselves. This activity aims to reduce anxiety and stress that may be present in some participants, encourage group interaction, and encourage participants to recognize and build upon their shared characteristics or interests.

Directions: Each person will be thrown a ball and once they have the ball they will share their name and answer a prompt related to race, diversity, discrimination, or inclusion. Individuals will also be asked to share what they hope to learn from this workshop. The ball will be thrown to every participant until each participant has shared.

Name: My Identity in Circles

Topic for activity: Self-awareness

Goals: The objective of this activity is to engage participants to identify what they consider important dimensions of their own identity. Biases and stereotypes are examined as participants share stories about themselves and the components they considered most important their identities. This activity aims to highlight the multiple dimensions of one’s identity and addresses the importance of individuals self-defining their identities and challenging stereotypes. COUNS LEBANESE AMERICANS 28

Directions: Each participant will place their name in the center of a circle and draw satellite circles connected to the center with identifiers or descriptors that is important to their identity.

These identifiers or descriptors may include anything such as: Asian American, female, father, athlete, educator, immigrant, Christian, career profession, age, sexual orientation, race, ethnicity, or any descriptor with which they identify with. Then once this has been completed, each participant will:

1. Share a story they felt proud to be identified with one of their descriptors.

2. Share a story they felt ashamed/painful to be identified with one of their descriptors.

3. Name a stereotype that is associated with one of their descriptors but that is not consistent

with who they are. “I am (a/an) ______but I am not (a/an) ______.”