Arab-American Muslims and psychotherapy: Perceptions affecting utilization of treatment
Arab-American Muslims vi Table of Contents Signature Page ii Acknowledgments iii Abstract iv Table of Contents vi Introduction 1 Chapter One: Literature Review 3 The Relationship of Islam and Psychotherapy 3 The Relationship of Culture and Psychotherapy 8 The State of Arab-American Muslim Mental Health 11 Means Used to Manage Psychological Distress 13 Central Focus of Study 20 Research Questions 22 Chapter Two: Methods 23 Selection of Participants 23 Procedures 25 Analysis 28 Ethical Considerations 30 Chapter Three: Results 33 Operationalization of the Study 33
Arab-American Muslims vii Taxonomy of Extracted Themes 36 Summary of Results 54 Chapter Four: Analysis and Discussion 56 Areas of Agreement Between Current Literature and this Study 56 Areas of Divergence Between Current Literature and this Study 62 The Construction of Dialogue 64 Implementation of Participant Suggestions Based on Commonalities.64 Limitations of the Study 69 Conclusions and Summary 71 References 72 Appendices 77 Appendix A: Script for Presentation to Imam/Mosque Leader/Representative 77 Appendix B: Script of Group Introduction 80 Appendix C: Consent to Participate Form 83 Appendix D: Consent to Audio Record 87 Appendix E: Participant Profile 88 Appendix F: Discussion Group Questions 89 Appendix G: Out-of-Group Topics 92 Appendix H: Debriefing Script 93
Arab-American Muslims viii Appendix I: Institutional Review Board Approval Form 94
Arab-American Muslims 1 Arab-American Muslims: Perceptions Affecting Utilization of Treatment Arab-American Muslims comprise a growing population in the United States. Their presence in this country has come under increasing scrutiny by the general populace and the news media. This increased awareness is due not only to the prominence of Arab Muslim terrorist groups claiming to act in the name of Islam and Allah, but also due to the more usual integration process of an immigrant population as they bring elements of their culture and religion to their new home. The presence of new mosques, additions of food items in grocery stores and Arab Muslim children in the schools all serve to introduce the general population to the increasing presence of this community in the United States. As with any group of people, individuals within the Arab-American Muslim community find themselves in need of community services, including mental health services. Occasionally, one hears news reports regarding mental health services which are available to this particular community. However, the availability and utilization levels for these services are not readily apparent. Also conspicuous by their paucity are
Arab-American Muslims 2 reports telling how individuals within the Arab-American Muslim community view such services. The literature review conducted for this study began with multiple searches in the PsycARTICLES database using various combinations of the keywords Arab-American, Muslim, psychotherapy, and Islam. The search expanded to include books and dissertations with material on the perspectives of Muslims, particularly Arab-American Muslims, toward psychotherapy. The final stages of the review accessed sources cited by writers already reviewed, until no significant new sources appeared. In addition to identifying areas where research of service utilization by Arab- American Muslims is less than comprehensive, this review explores the existing foundation within Islam for the study of the relationship between psychotherapy and Islam. Islam has a rich history of scientific discovery and innovation. There is a consistent tradition of seeking to understand mental illness and providing humane treatment for the mentally ill.
Arab-American Muslims 3 Chapter 1: Literature Review The Relationship of Islam and Psychotherapy The history of psychology in Islam. Islam describes itself as a theme, an all-encompassing description that goes way, way beyond the boundaries of religion. Thus, Islam is not just a religion; it is a political system and a method of social organization. It is a methodology of solving mankind's spiritual, practical, and intellectual problems. Islam therefore is a culture and civilization and a world view - a living, dynamic total system. (Husain, S.A. 1998, p. 285) Islam, as a cohesive entity, has a rich scholarly history dating to its origin in the Early Middle Ages. The caliphs of the seventh and eighth centuries encouraged the translation into Arabic of Persian and Greek academic literature, especially in the disciplines of science and medicine (Youssef, H., Youssef, F., & Dening, 1996). One of the earliest Islamic academicians in the field of psychology was Al Kindi (801-873 C.E.). He wrote primarily on cognitive functions and about the soul. Al Farabi (870- 950 C.E.) was concerned mainly with the discipline of Social Psychology. This is evidenced in his most well known work, Model City, a metaphorical comparison of the components of a metropolis with the various functions
Arab-American Muslims 4 of the human body. Early in the eleventh century the famous Ibn Sina, known in the West as Avicenna, wrote his Al-Shifa on cognitive processes, psychosomatic issues, perception, and emotions. Al Ghazzali (1043-1111), another well known Islamic scholar, studied the nature of the self, the essence of a human. He conceptualized the self using four terms heart (qa/b), soul (nafs), desire (shahwaniyyah), and intellect (aql), each of which is a spiritual entity. For Al Ghazzali, the intellect was the key to all human functioning. He studied many facets of psychology, including interpersonal relationships, abnormal behavior, emotions, and social behavior. (Vahab, 1996) Mental illness in pre-modern Islamic society. Al-junun is the term used in Islamic society for madness. The phrase mental illness is associated with Western psychiatry and is viewed as a clinical term. Al-junun refers to either the condition caused by jinn (spirit) possession, or the person who exhibits socially aberrant behaviors. (Al- Issa, 2000, p. xv) Youssef, H. et al. (1996) note the inclusion of madness as a major element in plot of The Thousand and One Knights. They infer from this usage that medieval Islamic society recognized the existence of mental illness with little stigma attached to the condition. In a similar vein, they refer to the old saying "Al-Junun-Funun," "madness of many
Arab-American Muslims 5 kinds." While possession by the jinn is a common notion in Arab Muslim culture, Islamic academia has, from its inception, looked elsewhere for the causes of mental illness. It is clear from historical records that Early Medieval Islam had identified mental illness as an entity separate from physical illness. Ninth century Baghdad, twelfth century Cairo and Damascus, and Tulun in 872- 3 C.E. each had a maristan, an asylum for the insane. Letters and journals by travelers in this era describe the humane treatment received by the mentally ill. These writers clarify that while the insane were bound by chains, they were restrained for their own protection and the safety of those around them. Based on the Galenic theory of the humors, mental illness was believed to be the result of an imbalance in the humors, perhaps burnt yellow bile or black bile reaching the brain. Insanity could therefore be treated with the same interventions as physical illnesses, e.g., diet, baths, and topical treatments. Ibn Sina, in particular did not hold to the popular notion that mental illness was simply attributable to the jinn, but that it could be explained by physical causes, e.g., bile/humoral theory. Medical texts of the time evidence a matter-of-fact, non-judgmental, empathic perspective. (Dols, 1987)
Arab-American Muslims 6 Ar-Razi, a physician of the tenth century, distinguishes between depression and confused thinking. In his work Kitab Al-Hawi, he writes that the depressed person has "gone astray" but the confused person is "agitated with persistent mental confusion". Ar-Razi also clarifies that such a confused person is not epileptic because persons with epilepsy are not confused between occurrences. In Al-Qanun, Ibn Sina wrote three chapters on neuropsychiatry- He defines the madness commonly referred to as junun as a "condition in which reality is replaced by fantasy". He distinguishes this from bipolar disorder, and describes symptoms in great detail (Youssef, H. et al., 1996). The mid-eleventh century writings of Said ibn Bakhtishu express skepticism for an exclusively physiological explanation for mental illness. This physician seems to suspect a source within the mind itself. He cites the treatment techniques used by caregivers in asylums that address a mental cause rather than a physical one. (Dols, 1987) These early physicians viewed mental illness as a disease of the brain, acute or chronic, and often heritable. Historically, Islam did not consider mental illness to be a result of sin or demon possession. It was not a condition deserving of punishment, and the sufferers were not stigmatized. Youssef, H. et al. (1996) highlight the Koranic emphasis on
Arab-American Muslims 7 taking care of the incompetent and managing their property. (Sura 4:4, The Koran) The concept of the self in Islam. "Islam is a complete system of beliefs - indeed a complete way of life. It governs the relationship between a human being and the Creator as well as the relationships among human beings themselves." (Ansari, Z., 2002, p. 325) Islam has a tripartite view of the human being, comprised of body, mind, and spirit. The mind, the psychological component, regulates body and spirit, and mediates between them. It is synonymous with the terms soul and self, and all three English terms are embodied in the Arabic word nafs/nephesh. In the opinion of Ansari (2002), Islam is essentially proactive in the scientific pursuit of understanding the human environment. Religion and science are not thought of as being in opposition. Nature and the environment are valued and their influence on humans should be studied and utilized whenever possible. Such valuing of the natural environment facilitates the compatibility of Islam with psychology, and the developmental theories of Piaget and Bandura in particular. (Ansari, 2002)
Arab-American Muslims 8 Haq (1992) provides a helpful summary of the compatibility of Islam and psychology. Islam views human nature as essentially good. The job of psychology is to bring persons back to their original nature. It is the return to congruence with the self as it was created that will result in inner peace. Psychology is the bridge to facilitate realignment of the self with the divine essence and to promote healing. Academicians within the Islamic psychological community, both in the U.S. and in Islamic nations, present similar themes in their discussions of the interface between Islam and psychology. Any seeming differences are more matters of emphasis than essential disagreement. The relevance of Islam to psychology and daily life is one prominent theme (Husain, 1996). Other scholars examine the compatibility of Islam and psychology (Ansari, 2002). Many writers address the importance of educating both Islamic and non-Islamic clinicians regarding aspects of Islamic culture that might impact the course of psychotherapy (Husain, 1998, & Hedayat-Diba, 2000). Relationship of Culture and Psychotherapy Cultural awareness and sensitivity on the part of the clinician are often addressed by writers who wish to increase the levels of service utilization by the Arab-American Muslim community. Clinician ignorance regarding
Arab-American Muslims 9 the values of Islam, disregard for family organization, and lack of respect for social customs are among the issues frequently addressed. These articles often provide didactic material on Arab culture and Islam in order to educate clinicians and improve cultural competence. Suggestions are sometimes given for incorporating religious and cultural practices into the treatment plan. Erickson and Al-Timimi discuss the clinical environment, particularly in terms of therapist bias. They explore the assumptions that Western clinicians commonly have, perhaps without realizing it, about Arab-American Muslims. Clinicians often believe that Muslims are violent, religiously conservative, and oppressive toward women. The authors recommend strategies to reduce clinician bias and stereotypes, and suggest treatment interventions that are culturally sensitive and appropriate. (Ali, Liu, & Humedian, 2004; Erickson, & Al-Timimi, 2001.) Hedayat-Diba (2000) addresses the problem of service underutilization by emphasizing the need to educate clinicians about Muslim religion and culture. As an experienced Muslim psychologist, she is widely quoted as a resource on psychotherapy with Muslims. However, it must be kept in mind that much of her material, while insightful and informative, consists of assumptions and opinions based on her clinical experiences. Her comments are not based on empirical study and as such are not readily
Arab-American Muslims 10 verifiable. Hedayat-Diba believes that the perception of Muslims in the U.S. toward psychotherapy is negative, and that this results in underutilization of services. Among the issues she has identified during her clinical practice are client suspicion toward the therapist and a lack of trust in psychotherapy as it is practiced in the West. She sees these attitudes as the primary impediments to establishing a therapeutic alliance with Muslim clients. She does not address Arab-American Muslims specifically, nor does she empirically substantiate any reasons for the client perceptions she has observed or why or how these perceptions impact the decision-making process for seeking psychotherapy. (Hedayat- Diba, 2000) Phenomenological explorations of the Arab-American Muslim therapy experience tend to involve a limited sample of clients. Kobeisy (2004), an imam and therapist, presents his research on seven of his own clients in his work Counseling American Muslims. In this study, he analyzed client input from the perspective of symbolic interaction. Kobeisy stresses the importance of imparting cultural knowledge to clinicians, and raising their level of awareness, rather than producing a study specifically designed to uncover Arab-American Muslim ideas and experiences regarding utilization of psychotherapeutic services.
Arab-American Muslims 11 Some researchers propose treatment models designed to accommodate and integrate specific cultural and religious nuances from the Arab-American Muslim population. Carter and Rashidi (2003) explore possibilities of using cognitive behavioral therapy with Muslim women and propose a model of treatment based on this experience. The researchers do not discuss specific techniques, but focus on religious and cultural issues and their compatibility with aspects of cognitive therapy. (Carter, & Rashidi, 2003; see also Ali, Liu, & Humedian, 2004) The State of Arab-American Muslim Mental Health Arab-American Muslims constitute a minority population in the U.S. that has unique pressures leading to significant levels of depression and anxiety. Recent studies of the Arab-American Muslim community have identified a direct correlation between depressive and anxiety disorders, and the various stressors which accompany immigration, integration, acculturation, and assimilation. These findings are consistent with those of earlier research, as well as with studies of immigrant and minority groups as a whole in the U.S. For her doctoral dissertation, Mona Amer (2005) conducted a survey of six hundred and eleven Arab Americans from thirty-five states. Nearly twenty-five percent of the respondents in that study reported moderate or
Arab-American Muslims 12 severe anxiety and approximately half of the persons studied reported symptoms of depression at clinically elevated levels. There is some evidence that the incidence of anxiety and depression in this population is much higher than in the normative samples. When the Arab-American Muslim population is studied using questionnaires and surveys, the responses have been called into question due to the Arab-American Muslim perceptions of illness. There is a documented tendency for this population to somatize their emotional distress. Such a tendency adds a confounding variable to this type of research which is difficult to control. (Aloud, 2004) The risk of suicide must also be weighed when examining the prevalence of mood disorders. In her work with the Arab-American Muslim population, Hedayat-Diba (2000) has identified a positive correlation between one's degree of Westernization and the risk of suicide. Arab-American Muslims are targets of discrimination in a post-911 world. Arab-American Muslims have experienced not only the trauma of all U.S. residents from 9-11, but also a direct assault on their religious assumptions and practices. This may lead Muslims in the U.S. to feel conflicted about their faith. (Inayat, 2005)
Arab-American Muslims 13 Amer (2005) does voice concerns regarding the effect of confounding variables such as culture-specific reporting styles and variations in research designs. Even in the face of these variables, the presence of significant mental health issues within the Arab-American Muslim population is undisputed. (Amer, 2005) Means Used to Manage Psychological Distress Native healing methods. The current literature includes some discussion regarding the use of traditional Arab-Muslim healing practices among Arab-American Muslims, but data quantifying levels of utilization are scarce. These practices include visiting shrines, consulting the local herbalist, participating in certain healing cults, and obtaining exorcism to expel the jinn (evil spirits). Talismans, exorcism, herbs, and other treatments may or may not be utilized in the United States, depending on availability and personal preference. Their efficacy is also the subject of discussion, with variable success reported. Accounts of successful healings using traditional methods tend to be dated and they are usually from the Arab-Muslim community at large. Typical of these reports are accounts cited by Al-Issa and Al-Subaie (2004) and from Kennedy (1978) and Pierre (1993). In the former report,
Arab-American Muslims 14 a woman with seemingly psychotic behaviors participated in a week-long healing cult ritual and was reportedly healed of her alleged thought disorder. She subsequently married and bore two children. In the latter report, the unsuccessful methods of ethnopsychoanalysis are contrasted with the effective treatment strategies of the patient's imam. The imam conceptualized the patient's apparent visual hallucinations in terms of jinn activity and provided interpretations regarding her life situation. The imam also instructed this woman to avoid walking near dirty water, a frequent habitat of the jinn. She was reportedly cured of her disturbing visions. (Al- Issa & Al-Subaie, 2004) Family support. There is a strong tendency within Islam, exemplified in many of the sources reviewed for this study, to place considerable importance on the extended family as a critical resource in times of psychological distress. A frequently quoted passage from the Koran illustrates this value: "And entrust not to the incapable the substance which God hath placed with you for their support; but maintain them therewith, and clothe them, and speak to them with kindly speech." (Sura 4:5, The Koran) The family may have been a significant source of support and healing in the past in the
Arab-American Muslims 15 country of origin. However, for families who have immigrated, this resource is typically not readily available. (Hedayat-Diba, 2000) Utilization of mental health services. Although a multitude of services exists in the U.S. to help those in distress, the level utilization by Arab-American Muslims is lower than other groups. There is an apparent reticence among Arab-American Muslims to access these services in times of psychological distress. Much of the data documenting service utilization patterns come from quantitative studies. Their methodologies examine readily quantifiable domains such as gender, age, and positive or negative opinions about services (Kahn, 2006). Typically, these studies examine persons who are already familiar with mental health services in some way. Persons unfamiliar with mental health services are rarely consulted for their preferences. An example of this type of study is Khan's (2003) survey of Muslims in the Toledo, Ohio area between May and October of 2002. Attitudes toward counseling were categorized as either positive or negative, then correlated by age, gender, education, socioeconomic status, ethnicity, perceived need, and use of services. Findings included a significantly greater tendency of males to have negative attitudes toward counseling
Arab-American Muslims 16 than females, and no significant difference in attitudes based on level of education. (Khan, 2003) In another quantitative study, specific attitudes were identified as predictors of service utilization. These attitudes were then discussed in the context of a specific social-service model to determine strategies needed to improve access and to increase levels of utilization. One significant finding of this study revealed that when mental illness is perceived as the will of God, either as a test or a punishment, then illness is tolerated as an act of compliance with the will of God. In this instance, service utilization is not an option. This perspective may, however, result in a disproportionately heavy reliance on traditional methods of healing. (Aloud, 2004) In an Australian study of Arabic-speaking persons, irrespective of culture or religion, Youssef, 1 and Deane (2006) used a snowball referral method to obtain knowledgeable persons within this community who could comment on utilization of services. This study did not interview persons about their process of deciding whether or not to seek treatment. It somewhat resembles a community meta-analysis in that it uses the opinions of professionals within a community and their perspectives as observers of that community. These observers identified shame and
Arab-American Muslims 17 stigma regarding mental illness as the primary impediments of service utilization. (Youssef, J., & Deane, 2006) This study exemplifies how pivotal issues critical to an understanding of the Arab-Muslim community are frequently omitted or overlooked. There is no exploration of the deeply rooted non-stigmatizing conceptualization of mental illness within Islam. There is no discussion about how to better educate laypersons within the community regarding this historic perspective. Neither does this study make an inquiry into the existential elements of an individual's decision-making process to seek mental health treatment. As Erickson and Al-Timimi (2001) reiterate in their conclusion, there is a "critical need for research on the mental health experiences of Arab Americans." To put it another way, there is a conspicuous need for phenomenological research on issues related to service utilization by Arab- American Muslims. Spiritual resources. Islam itself is often a resource for persons in psychological distress. Spiritual leaders, imams, may employ pastoral counseling techniques and strategies specific to Islam. Particular verses from the Koran and Islamic spiritual rituals are often employed to minister to members of their community (Inayat, 2005). The Koran and prophetic tradition (hadith) are
Arab-American Muslims 18 the primary resources for guidance in the treatment of all illness. The two most frequently implemented treatment methods within Islam, across all cultures, include invoking the name of God and reciting passages from the Koran. With these practices, there is no need for a healer as a go- between. They facilitate a direct connection with God. A very popular healing ritual is the writing out of verses from the Koran, soaking them in water and then giving the water to the sick person to either wash with or drink. (Al-Issa & Al-Subaie, 2004) Religious activity and the acts of ritual are considered to be both preventative and curative. As one participates in the movements of worship, one engages in the process of enacting the cure. Prayer activity that involves changing physical position is said to facilitate relaxation, which in turn, can ameliorate types of back pain, for example. (Husain, 1998) Related to this healing strategy are the suggestions of Al-Abdul-Jabbar and Al-Issa (2000). From their experience within both Islam and psychology, they recommend that the clinician identify specific religious acts that can be conceptually related by the client to the particular psychological problem, then have the client perform these acts as a way of working through the problem. An example of this strategy applies to
Arab-American Muslims 19 the compulsive washing of Obsessive Compulsive Disorder. Islam provides for alternative forms of ritual cleansing before prayer if, for example, clean water is not available. The client may instead touch clean sand to address their compulsion to wash. They may extend this touch to the entire body as a cleansing ritual that does not trigger compulsive washing with water. Another suggestion, also for Obsessive Compulsive Disorder, utilizes the group prayer format to interrupt the compulsion for repetitive individual praying. Group prayer settings can also help with social phobia, as the client uses the group as part of a desensitization process. Ritual acts before and during prayer can also be used as relaxation techniques to reduce anxiety. (Al-Abdul-Jabbar & Al-Issa, 2000)
Arab-American Muslims 20 Central Focus of Study Within the Arab-American Muslim community there exists a documented need for mental health services, but the process of deciding whether to access those services remains relatively unexplored. There is little clear understanding of how Arab-American Muslims make the decision to enter mental health treatment or to seek help elsewhere. The majority of current research uses predetermined, easily quantified response categories. However, this type of research does not elicit the existential phenomena that impact the help-seeking process. Often, such studies obtain their data from individuals who have used or who are currently engaged in mental health services. This approach overlooks those persons for whom mental health services might be an option in the future or someone who might reject such services. From a phenomenological perspective, their perception of psychotherapy is virtually unknown. Current research provides limited insight into the influence of self- perception on the decision to seek services, especially in the context of the dominant U.S. society. The healing arts have a long-standing tradition within Islam, yet there is little existential awareness on the part of the U.S. clinical community regarding the Arab-American Muslim experience of
Arab-American Muslims 21 traditional healing practices and the healing elements within Islam. Neither is there a clear picture of the Arab-American Muslim's expectations of Islam and traditional healing methods compared with U.S. mental health services. The U.S. clinical community has a limited understanding of Islam's conceptualization of mental illness, how this conceptualization has evolved, and to what degree this evolution has been affected by interactions with U.S. society and culture. While Islamic scholars in predominantly Muslim nations call for an Islamic epistemology for the study of psychology, little has been undertaken to implement their proposals. In the U.S., few if any attempts have been made to construct an epistemology of psychology based on Islamic conceptualizations of the human psyche, soul, cognitive functions, senses, and behavior. There are points of contact between secular psychology and the Islamic view of humanity, but little effort has been made in the U.S. to build on those commonalities, particularly from a phenomenological perspective. Clearly, there remains much to be studied regarding the Arab- American Muslim community and its interface with the U.S. psychological community.
Arab-American Muslims 22 Research Questions 1. What are the perceptions among Arab-American Muslims that impact their decision-making process, regarding utilization of psychotherapy, in times of psychological stress? 2. Do these perceptions vary between different age groups, generational identity, or time in country? 3. Are there multiple meanings within the Arab-American Muslim community for mental illness? 4. Is there a connection between the meanings for mental illness and the meanings for demon possession? 5. Have the concepts of "help-seeking," "family loyalty," "privacy," and their traditional meanings within the Arab-American Muslim culture changed, or is there variation? 6. Why does some research show an overall positive attitude toward mental health services, yet utilization patterns among Arab-American Muslims remain inconsistent?