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Arab Americans, Other Cultures Wary of Treating Mental Illness

By Jessica Adler
Herald News
Posted on Tuesday October 18, 2005

Limya Salman didn’t know why it was happening, but she knew she couldn’t control it. She had just given birth to her first child – the family’s first granddaughter – and she couldn’t stop feeling sad and scared.

She cried. She had trouble eating and sleeping. Panic attacks sometimes made her body shake uncontrollably and left her breathless.

She was so happy to be a mother, but she found herself worrying constantly, “What if something happens to my daughter?”

To those who knew Salman best, it was an extreme version of her nervous personality. Her parents and husband tried to help.

“God gave you a beautiful daughter and a wonderful husband, and you have us here,” her parents reassured her. “We’re here for you.”

Their words comforted Salman. But they didn’t eliminate the sleeplessness or the panic attacks.

That was nine years ago. Back then, Salman had never heard of postpartum depression – or considered seeing a therapist. Mental health experts suggest many reasons for her reluctance to seek help, beginning with the fact that Salman is Arab-American. That, they say, has everything to do with both her outlook on depression and on counseling.

When it comes to attitudes about mental illness, culture matters.

“Mental health has a huge stigma in the Arab-American community,” said Gladys Yachouh, director of crossover programs at the Mental Health Association of Passaic County (MHAPC). “And there are a lot of barriers to getting services.”

In April, the MHAPC received a $15,000 one-year grant from the State Division of Mental Health to work toward countering the problem. The organization created a task force of mental health professionals from hospitals, community-based organizations and Arab-Americans – local religious leaders, social advocates and people with mental illness and their loved ones.

The group has a broad mission: clarify aspects of Arab-American culture, including religious practices, gender roles and how Arab-Americans traditionally handle mental illness; study how to increase Arab-American usage of community mental health services; and illuminate the benefits of those services.

“Arab culture is characterized as a shame culture,” said Radwan Khoury, executive director of the Arab American and Chaldean Council, which is based in Detroit and provides mental health and other social services to people of Middle Eastern descent. ”(Arab-Americans) believe they should really take care of themselves and not really go out to seek help.

“Going out and seeking help means that people are going to find out that this family has a mental case in the family and, therefore, they will start to be looked at as not really at the level of other normal families without any mental illness.”

That’s an important reality in Passaic County, home to almost 11,000 residents of Arab ancestry, according to the 2000 Census. The Census also cites Passaic, Bergen and Hudson counties as among the top 20 U.S. counties for Arab populations.

“Family honor in Arab culture is very important,” said Adnan Hammad, director of the Community Health and Research Center at the Arab Community Center for Economic and Social Services in Dearborn, Mich.

For example, Hammad said, Arab-American immigrant parents might believe that public acknowledgement of a family member’s mental illness – schizophrenia, for example – will make a woman seem a less desirable wife.

Arab-American attitudes toward mental health also are defined by a firm belief in fatalism, or “the acceptance of the will of God as related to health and sickness,” Hammad said. A parent might believe, ”’If God wills it that my son is mentally ill, why should I bother getting help? God wants it that way.’”

Ideals of family honor and fatalism, Hammad said, are inherent in Arab culture, whether a family is Christian or Muslim.

And those ideals aren’t unique to Arab-Americans, said Anu Singh, coordinator of the South Asian Mental Health Awareness in Jersey program (SAMHAJ), which is sponsored by the National Alliance on Mental Illness.

Some South Asian Buddhists and Hindus believe in karma, which dictates that “whatever hardships I’m going through in this life are part of my paying penance for bad deeds I committed in previous lives,” she said. Such an attitude, she added, applies more often to mental illness than other health issues, like diabetes and heart problems.

When mental illness strikes, an Eastern or South Asian family is likely to undergo three stages of coping, said Singh. The first is denial, the second to seek help from a spiritual or religious leader. The third – a visit to a mental health professional – occurs only “when nothing else helps,” she said.

That pretty much sums up Limya Salman’s path to treatment. At first, she believed she was responsible, that she could control her thoughts and feelings. When the panic attacks and depression got worse, she went with her mother to mosque. “What you need is strong faith,” her family told her.

In spite of the comfort Salman found in prayer and religion – she still goes to mosque every week -her anxiety and tears didn’t subside. She didn’t understand. She loved being a mother. She was so thankful for her family’s unconditional support. But the terrible feelings wouldn’t go away.

Finally, a friend suggested counseling. When a psychiatrist diagnosed postpartum depression, the young mother asked, “What is that? What are you talking about? Everybody has babies.”

Salman eventually felt relieved to have a name for what she was going through. Above all, she was relieved to hear the doctor say, “You are not alone.”

That’s the mantra Salman repeats to her clients at MHAPC, where she now works as a community peer educator. And she now believes that a combination of religion and therapy can help a lot. She isn’t surprised to know that a patient’s cultural perspective -religion, family structure, traditions of an immigrant’s homeland – is among the most challenging faced by mental health professionals.

“When clinician and patient do not come from the same ethnic or cultural background … clinicians may be more likely to ignore symptoms that the patient deems important, or less likely to understand the patient’s fears, concerns and needs,” said a 2001 Surgeon General’s report entitled “Mental Health: Culture, Race, Ethnicity.” “The clinician and patient also may harbor different assumptions about what a clinician is supposed to do, how a patient should act, what causes the illness, and what treatments are available.”

Salman, for one, values having a Muslim woman as her therapist.

“Cultural similarity does help,” said Dr. Nighat Mirza, the Paterson psychiatrist who treated her. Talking about relationships and family dynamics, Mirza’s own Muslim and Eastern background – she was born in Pakistan – help her connect with certain patients, she said.

“Some (clients) come from a distance because they want to see a Muslim psychiatrist,” she said.

At its monthly meetings, the MHAPC task force has discussed the shortage of Arab-American clinicians. (Mirza estimates there are five or so in all of Passaic County). The group has discussed the need for health-care providers to be more culturally aware. And it has discussed how to educate the Arab-American community about such illnesses as postpartum depression. The group’s efforts will culminate in two presentations: one in November, to parents at Public School No. 9 in Paterson, the other in December, to mental health professionals at Barnert Hospital.

Limya Salman will be among the speakers in November. She’ll talk about her personal experiences, in hopes of helping parents understand that mental illness is real and that, sometimes, a doctor can help.

“Why sit and suffer,” she asks, “when there’s help out there?”