The United States of America is a nation that reflects diverse cultures. It would be illogical, unethical, and in some instances, unlawful to practice social work from a monocultural perspective. The purpose of this paper is to raise awareness of the Arab-American population for social workers. Like most immigrants, Arab people have been migrating to the United States for generations. Arab-Americans, like any other culture, have risk and protective factors. Recent world events have left some Americans with negative impressions of Arabs, Arab-Americans, and the Muslim people. This has resulted in some cases of discrimination and verbal and physical assault. The culturally competent social worker should identify cultural and patient values and the beliefs of his or her target population. If these values and beliefs are different from the social worker's own value and belief systems, the social worker should be prepared to draw upon pre-identified resources to deliver equitable and effective treatment.
INTRODUCTION
According to the 1990 and 2000 Censuses, the exact number of Arab-Americans, or Americans with Arab ancestry, is not known. However, it was reported that there were just over 100 million who identified themselves as having Arab ancestry, a number De la Cruz and Brittingham (2003) agree with. By contrast, Kasem (2004) tells us that more than three million Americans have Arab ancestry, and that the census numbers are underrepresented for a variety of reasons. Underreporting may be due, but not limited, to the fact that: (a) the Census provided only one in six households with the long form—the short form did not ask about Arab ancestry (b) not all households answered the Census (c) some Arab-Americans, fearful of bigotry or discrimination, may not have answered truthfully and (d) some Arab-Americans have been mixed with other races and may not clearly identify themselves with Arab ancestry.
Arab-Americans reside in all 50 states of the United States. However, the Census 2000, as reported by de la Cruz and Brittingham (2003), reported that approximately half of the Arab population was concentrated in five states: California, Florida, Michigan, New Jersey, and New York. “These states contained 31 percent of the total U.S. population" (de la Cruz & Brittingham, 2003, p. 4). The purpose of this paper is to sensitize social workers to risk and protective factors of the Arab-American population and to offer general recommendations to improve cultural competence.
Definition of Terms
For the purpose of this paper, these six specific terms required clarification:
Chaldean. Also spelled as Chaldaean. A noun used to refer to religion or to a member of Semitic-speaking people of the Middle East and Northern Africa or to refer to those speaking the language and culture of Chaldea.
Cultural Broker. Varying definitions, however, it is generally an individual trained to act as a mediator or negotiator who seeks to bridge gaps between different cultures.
Shi'ite. The second major division of the Muslim faith. A sect of the Muslim faith that split with the Sunni over the issue of the successor to Muhammad.
Suffi. The third major separation of the Muslim faith. A sect of the Muslim faith in which their belief system is a Muslim adaptation of the Indian Vendantic Philosphy.
Sunni. The majority sect of the Muslim faith. They are followers of the Hanifa, Shafi, Hanibal, and Malik schools.
Zar. A general term used to describe possession of spirits within an individual. This term is general applied in North African and Middle Eastern societies.
REVIEW OF THE LITERATURE
Identity and Values
Arab-Americans have emigrated in waves from 22 diversified countries including:
(a) Afghanistan, Egypt (b) Israel (c) Jordan (d) Lebanon (e) Pakistan (f) Saudi Arabia (g) Syria (h)Turkey, and (i) Yemen (Eversole, n.d.). As with any culture, identity and values vary among individuals. The term Arab refers to individuals who speak Arabic, and who belong to the Semitic race—with roots leading back to the Arabian Peninsula (Suleiman, 2000). However, Samhan (2001) offers this definition of Arab-American identity and values:
Arab-Americans are as diverse as the national origins and immigration experiences that have shaped their ethnic identity in the United States, with religious affiliation one of the most defining factors. The majority of Arab-Americans descend from the first wave of mostly Christian immigrants. Sharing the faith tradition of the majority of Americans facilitated their acculturation into American society, as did high intermarriage rates with other Christian ethnic groups. Even though many Arab Christians have kept their Orthodox and Eastern Rite church (Greek Catholic, Maronite, and Coptic) affiliations, which have helped to strengthen ethnic identification and certain rituals, their religious practices have not greatly distinguished them from the Euro-centric American culture. Roughly, two-thirds of the Arab population identifies with one or more Christian sect. (para. 2)
Languages
Many Arab-Americans have been in the United States for more than one generation. “Do not assume that an Arab American should know Arabic, any more than any other American should speak the language of his or her ethnic group" (Detroit Free Press, 2001, p. 1). As with American English, even if Arabic is considered the primary language of the Arab-American, Arabic language varies with regional dialects and regional vernaculars. Other Arabic languages may include, but are not limited to, Farsi, Burber, and Kurdish, and many Arab-Americans will speak more than one language fluently.
Risk Factors
Recent events in the United States and throughout the world have drawn attention to Arab-Americans, Arabs in other countries, and to Muslims. In the United States, that attention has not been favorable. Since drama sells and the truth is boring, the U.S. mainstream media often groups all Arabs together. It also provides some Americans with negative images of and stories about Arab and Muslim people. Consequently, some Arab Americans have been victimized by discrimination, verbal and physical assaults, and other hate crimes.
Samhan (2001) points out that the Arab villain has been a frequent scapegoat in American cartoons and movies. Chebli (n.d.) agrees with Samhan and reminds us that early American cartoons had portrayed their villains as dark, big-nosed Arabs. Movies such as Not Without My Daughter, starring Sally Fields as an American woman who, along with her daughter, is held captive by her brutish Iranian husband, help support this type of racial and cultural profiling.
Efforts are underway across the country to counteract and contradict this stigma. The American prime-time television series Lost portrays the fictional character, Sayid, an Iraqi military veteran, in a more favorable light. That is, this character is not portrayed as the villain, but rather as one of the victims of the plight himself and as a vital part of the team as it relates to the television series. The recent New York Arab American Comedy Festival (2006) is another prime example. The festival employed six comical plays to tackle a wide range of topics that included Hollywood’s casting of Arabs and Arab-Americans’ fears of Arab terrorists.
As defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (2005), culture-bound syndromes such as zar can be a risk factor if misdiagnosed. What may be considered normal responsive behavior in one culture may be considered abnormal in another culture. Misdiagnosis can occur if the social worker is unable to recognize and understand the subtle nuances of such a syndrome, and thus potentially inflict unnecessary treatment and medication on a patient.
Protective Factors
Identifying protective factors can help social workers to better understand how to address the specific needs of a target population by identifying strengths and social, economic and health assets. Protective factors may include natural and structured supportive systems. Natural supportive factors may include financial and emotional support from immediate and extended family members to assist with housing, housing costs and other family tasks and close ties with the community. Structured support systems may include community or faith-based programs or initiatives such as free, low-cost, or sliding-scale physical and mental health services, translation services, interpretative services, and educational or vocational assistance. Arab-Americans who reside in communities with a high population of other Arab-Americans may find that the community itself is a positive resource community members may share like values, goals, problems, and solutions.
Religion
Religion can play an important role as a protective factor since it can provide meaning and help an individual understand and cope with a given situation, (McCormick, (n.d.). That is, individuals who hold strong religious beliefs and close ties with their religious leaders and community may find comfort, solace, or solutions in times of trouble or duress. Those individuals who are actively involved in their church, mosque, or other structural and official place of worship may find support by interacting with those who share their beliefs.
The U.S. mainstream media offers some distinction between the two major divisions of the Muslim faith, Sunni and Shi'ite, but offers little information on the Sufi Muslim, Chaldean, and other Christian Arab people or on the Atheist Arab people. Not all Arabs are Muslim, and not all individuals of the Muslim faith are Arab just as all Americans do not practice a religion, not all Arab people practice a religion. Thus, it is not appropriate to make religious assumptions.
METHODOLOGY
Research for this paper included exhaustive Internet searches and was restricted to the English language. The literature review consisted of exhaustive Internet searches that employed infoseek.com, ProQuest, and lycos.com, and used key phrases such as “social work and Arab Americans," “Arab Americans," “risk factors for Arab Americans," and “cultural competence for social workers" in varied combinations. Since recent world events may have had significant impact on some Arab-Americans, to keep information relevant, only information regarding Arab-Americans between 1998 and 2006 was reviewed.
RESULTS
Research revealed that there is a dearth of scholarly articles pertaining specifically to social work and Arab-Americans, and was redundant as it reiterated the definition or concept of what makes an individual an Arab or Arab-American. That is, Arabs are commonly associated with Middle Eastern geography and with the shared language of Arabic. The literature reiterated common beliefs regarding the Arab people and those individuals of the Muslim faith and that various beliefs and practices may be similar, but that beliefs systems and languages will vary within religion, families, and geographic location. The literature reviewed offered several risk factors for the social and physiological well-being of Arab-Americans, but offered few support factors.
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
Discussion
The purpose of this paper was to sensitize social workers to risk and protective factors of the Arab-American population and to offer general recommendations to improve cultural competence. Definitions and descriptions are not intended to be comprehensive, but rather, offer an initial level of understanding for social workers that are unfamiliar or under-familiar with the Arab-American population. Broad recommendations were given to offer suggestions for social workers to begin identifying suitable resources to serve this population.
There are various federal and state laws, patient bills of rights, and other regulations that prohibit any discriminatory practices. The most fundamental of these laws is the Civil Rights Act of 1964 and the Pryce Patient Navigator Bill of 2005. However, just because discrimination is unlawful does not instantly obliterate discrimination or discriminatory practices or beliefs. Myths and misunderstandings regarding cultures can cause the patient physical and emotional harm. To comply with federal and state laws, and professional ethics, it is necessary for the healthcare provider to continuously identify culturally competent deficits in their practice area, and to correct these deficiencies.
Competent evaluation and case management of ethnically diverse persons can be facilitated by the social workers’ understanding of the uniqueness of the patient’s cultural identity. Significant growth in minority groups within the U.S. is anticipated by the Center for Disease and Control (CDC) (2005), therefore, proactive approaches are needed to eliminate ethnic and racial disparities in health care. As the United States becomes more culturally diverse, it is necessary to address the specific and subtle needs of those patients who are not of the majority group. Healthcare professionals are increasingly recognizing that some health care initiatives fail in cultural aptness (Berger, 1998). More research is needed to gain insight and identify the needs of the growing Arab-American population. In addition, to enforce and support legal and ethical responsibilities, more education is required for all healthcare professionals.
Recommendations
The United States of America is a multicultural country that reflects its origin as a nation of immigrants. As such, it is illogical and unethical to practice social work from the perspective of a singular culture. Federal laws such as the Hill-Burton Act of 1946, and various state regulations of the individual state in which the social worker is licensed outline the legal requirements to providing culturally competent care. Additionally, professional social workers are guided by the code of ethics as outlined by the National Association of Social Workers (NASW) (n.d.). The NASW code of ethics dictates that social workers treat all people humanely, fairly, and equitably. General recommendations for social workers who work with the Arab American patient are provided. The recommendations are not exhaustive but may serve as a foundation to begin developing procedures and resources to best serve the needs of this population.
As professional social workers, the practice is distinctive from other helping professions in its approach of assisting clients to function optimally within their environments. Social workers have the opportunity to work in many practice areas (A. Galal El-Din, personal communication, January 31, 2006). Therefore, the social worker should design his or her cultural resources appropriately to best fit the particular practice environment.
Social workers should take caution when making assumptions regarding any particular culture. He or she should not simply consolidate the patient into a specific category of belief systems (Spector, 2004). Although many Arab-Americans may hold similar beliefs and values, they will not all hold the same beliefs and values.
Unlike, other medical professionals, individuals do not consult social workers for a wellness checkup. Rather, social workers are voluntarily consulted because the patient has recognized that they may be in need of resources, therapy, or other psychosocial support.. Patients also consult social workers because they are mandated by the courts to do so. Social workers who work with the Arab-American population in voluntary or involuntary mental health settings should be sensitive to the stigma that can be associated with mental health treatment. As it is with many cultures, “Mental illness is often stigmatized in Arab communities. A person with mental distress may not seek advice from professionals or even family members" (Management Sciences for Health, n.d., p. 2).
Social workers should also be able to identify specific cultural needs of the population with which they work. Cultural competence may include raising one’s own awareness about a culture that is different from one’s own. Any biases towards a patient culturally based or otherwise creates a barrier to treatment. As with other barriers to equitable treatment, any biases must be resolved. It is important to understand risk and protective factors, understand the patients’ belief systems, and not to impose one's own belief systems upon the patient.
A very essential part of cultural competence is removing language and any other communication barriers that may exist. There are various laws already in place to help foster promotion of equitable and culturally competent care. For example, Executive Order 13166 (Limited English Proficiency) signed by President Clinton, as defined in the Federal Register (2002), requires health care providers provide interpretation services for facilities or clinicians that receive federal enrichment. Federal enrichment is any form of federal assistance or funds, such as, but not limited to, Medicaid or Medicare reimbursement. The distinction between interpretive and translation services should be recognized. Mere translation may not convey critical meaning, connotation, or understanding therefore, it is recommended that competent interpretative services be employed when language is a barrier.
Psychosocial Assessments will vary depending on the setting of social worker’s practice. As final recommendations, if the social worker’s setting is lacking resources to treat individuals competently, he or she should continue to advocate for these resources. Social workers should consider including questions to draw out cultural nuances such as:
(a) level of acculturation (b) alienation issues
(c) displacement issues
(d) immigration experiences
(e) religion or belief systems, and
(f) language or other communication barriers.
Social workers should be mindful that patients may be hesitant to answer questions and feel that, if they answer, they may be discriminated against. To overcome this, social workers should explain the reason for the question before asking it and ensure the patient of applicable privacy rules.
Cultural competency goes beyond language barriers, proficiencies, or deficiencies. Although, there is no one all-inclusive definition of cultural competence cultural competence is the ability and willingness of an individual or other service-providing entity to deliver equitable and effective care or services. The providers should have a store of knowledge and resources to draw upon to help them recognize, appreciate, and bridge or remove any barriers to care that may exist due to an individual’s language, cultural practices, and beliefs. (Seattle King County Dept of Public Health, 1994, and CCHCP's Cultural Competency Curriculum, 1999, as cited in Nehrenz, n.d) Social workers must educate themselves so they can serve clients who are from different cultures or who hold values and identities different from the social worker’s own values and identity. A competent social worker should be able to identify the population of clients he or she is likely to serve. If the likely population varies from the social worker’s own cultural identity or belief systems, he or she should then develop an additional store of information and resources to draw upon to competently provide services or appropriate referrals for these clients or patients. Although Arab Americans reside throughout the country, social workers may find that immediate resources are scarce in their particular geographical location.
For those practicing in larger, populated Arab American communities, existing resources should be identified, and a working relationship should be honed. For example, the Arab Community Center for Economic and Social Services (Access) originally opened its doors to serve Arab Americans in Detroit, Michigan. Currently Access is located in Dearborn, Michigan and provides a wide range of services to include, but are not limited to, employment training, youth services, and social services (1999).
For less populated Arab American areas, it is best to pre-identify resources to help ensure that resources are more readily available for use either face-to-face, telephonically, or electronically. Resources may include: (a) cultural brokers (b) interpretative services (c) culturally competent medical or social work referrals, and (d) local, state and federal client resources or referral services.
REFERENCES
American Psychiatric Association. (2005). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Fourth edition: Text revision. Arlington, VA.
Arab Community Center for Economic and Social Services (Access) (1999). Guide to
Arab culture: Health care delivery to the Arab American community. Retrieved January 31, 2006, from:
http://www.accesscommunity.org/ documents/ACCESS_Guide_to_Arab_Culture_Health_Care _Delivery_to_the_Arab_American_Community.pdf.
Berger, J. (1998). Culture and ethnicity in clinical care. Journal Discussion. Arch Intern Med-Commentary, Retrieved, February 5, 2006, from:
http://webctce.nova.edu/ DHS_8000_1_32756_200630/pdf/culture_and_ethnicity_clinical.pdf1.
Center for Disease and Control (CDC) (2005) Office of Minority Health. Eliminating racial & ethnic health disparities. Retrieved February 11, 2006, from: http://www.cdc.gov/omh/AboutUs/disparities.htm.
Chebli, I. (n.d.) The portrayal of Arabs in American media. Retrieved January 17, 2006, from: http://iml.jou.ufl.edu/projects/Spring01/Chebli/frames.htm.
Detroit Free Press (2001). 100 questions and answers about Arab Americans: A
journalist's guide. Retrieved January 30, 2006, from: http://www.freep.com/legacy/jobspage/arabs/arab3.html.
de la Cruz, G., Brittingham, A. (2003). The Arab population: 2000. Census 2000
brief. Retrieved January 15, 2006, from: http://www.census.gov/prod/2003pubs/c2kbr-23.pdf.
Eversole, J. (n.d.) Cultural diversity: Eating in American Middle Eastern. Retrieved
January 31, 2006, from: http://webctce.nova.edu/DHS_8000_1_32756_200630/pdf/middle_eastern_eating.pdf.
Federal Register (2002). Vol. 67, No. 117 / Tuesday, June 18, 2002 / Notices. Retrieved
January 4, 2006 from: http://www.ojp.usdoj.gov/ocr/docs/DOJFinLEPFRJun182002.pdf.
Kasem, C. (2004). Arab-Americans: Making a difference. Retrieved January 15, 2006,
from: http://arabcomedy.org/news/article_115.shtml.
McCormick, T. (n.d.) Spirituality and medicine. Ethics in Medicine. [Electronic Version].
University of Washington School of Medicine. Retrieved March 10, 2006, from: http://webctce.nova.edu/DHS_8000_1_32756_200630/pdf/Sprituality_and_Medicine.pdf.
Management Sciences for Health (MSH) (n.d). The providers guide to quality and
culture. Retrieved, January 28, 2006, from: http://ecu3.msh.org/mainpage.cfm?file=5.4.2j.htm&module=provider&language=English.
National Association of Social Workers. (n.d.). Social worker code of ethics.
Retrieved January 15, 2006, from: http://www.socialworkers.org/pubs/code/code.asp.
Nehrenz, G. (n.d.). Cultural, disability, and illness. DHS 8000 healthcare for diverse
populations. Retrieved, March 14, 2006, from: http://webctce.nova.edu/DHS_8000_1_32756_200630/week_2_readings.htm.
New York Arab-American Comedy Festival (2006). In this section. The Arabs are
coming. Retrieved January 15, 2006, from: http://arabcomedy.org/news/article_115.shtml.
Samhan, H. (2001). Who are Arab-Americans? Retrieved January 15, 2006, from:
http://www.aaiusa.org/PDF/Grolier'sEncyc.pdf.
Spector, R. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle
River, New Jersey: Pearson Prentice Hall.
Suleiman, M. (2000). Teaching about Arab Americans: What social studies teachers
should know. (ERIC Document Reproduction Service No. ED442 714).
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