At the initial assessment session, the psychologist greeted Mouna and Majid warmly and introduced herself as Dr. Kate Smith. They chatted briefly, with Majid interpreting for Mouna, about the difference between the weather in the northeastern United States and Tunisia. Kate observed to herself that Mouna appeared very dressed up, with carefully done makeup, a stylish short haircut, and noticeable perfume. Mouna was alert and her affect seemed sad, but she smiled at appropriate times and, despite the language difference, always looked directly at Kate when Kate spoke. Majid was dressed neatly, although more casually. He showed a full range of affect but appeared tense. The couple seemed comfort- able interacting with each other; for example, twice Mouna spoke sharply to Majid, and he responded with an irritated look.
Kate began the assessment by asking Majid to explain why they had come in to see her. Majid said that he did not think they needed a psy- chologist but that the doctor couldn't find anything wrong with Mouna and told them they ought to see her. Kate sensed some embarrassment on his part. She said that she hoped she could be helpful and that she would like to start by hearing a bit more about their concerns. As Majid repeated the information he had told the physician, Kate periodically made eye contact with Mouna.
After about 15 minutes of talking with Majid, Kate asked him if he would interpret a few questions for her directly to Mouna. He agreed, and through this process, Kate learned that before marrying Majid, Mouna had lived with her parents and two brothers in the capital city of Tunis. Through a meeting arranged by family members, she was introduced to Majid on one of his visits home; they corresponded for a year and then married. Mouna left her work in a hospital and moved to the United States with Majid. During their first few months together, she was happy with her new life, but then she began to miss her family, her friends, and her home. She also began to worry about not being able to have children, because after 8 months of marriage she had not yet become pregnant. When asked what she wanted, she said that she wished to return to Tunisia with Majid, but in the same sentence she acknowl- edged that she knew he couldn't leave his work.
Because of the interpretation process, this initial assessment took the full 90 minutes scheduled. Although she did not complete her evalua- tion, Kate considered the meeting successful because Mouna brightened
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a little when questioned directly about her thoughts and feelings, and Majid appeared less tense than when he had arrived. When asked, both Mouna and Majid agreed to return for a second assessment session.
CONSULTATION TIME
At this point, Kate was well aware of her own limitations in working with Mouna and Majid. She had some experience working with people who had immigrated from South America and Europe, and she was familiar with some of the values and behaviors more common in Mediterranean cultures (e.g., the emphasis on family, the value placed on motherhood, and expectations of marriage and children for both men and women; see Abudabbeh & Hays, 2006; AH, Liu, & Humedian, 2004; Bushra et al., 2007). However, Kate had no personal or profes- sional experience with Tunisian, Arab, or Muslim people.
After listening to Majid, Kate realized that she held some assump- tions about Arab and Muslim men's attitudes toward women. For exam- ple, she was surprised by the sincerity of Majid's concern for Mouna and by their apparent comfort level with one another. In thinking about her surprise, she realized that she had assumed that given their arranged marriage, the couple would be quite formal with one another and that Majid would care about Mouna's health only insofar as it affected his needs. But this was clearly not the case. Kate realized that changing her biases would require work outside the therapy session.
Before their next session, Kate found information about Tunisia. She learned that Tunisia is a North African country of approximately 10 mil- lion people who are predominantly Arab and Sunni Muslim. The coun- try was colonized by France (technically a protectorate) until it gained independence in 1956. Tunisia has a high literacy rate and mandatory schooling for boys and girls, and French is a commonly spoken second language. During the past 40 years, Tunisia has become a leader in the Arab world on the subject of women's rights; minimum ages have been set for marriage, the consent of both women and men is required for marriage, abortion and divorce initiated by women have been legalized, and family planning services offer free contraceptives across the coun- try. The Tunisian government sends university students abroad for graduate study in particular fields. Although most go to France, some are sent to the United States, and many of these individuals become per- manent residents (Hays & Zouari, 1995; World Almanac Education Group, 2007).
Kate also consulted with an Arab American therapist, who advised her that she should have arranged for an interpreter before their first session. Kate telephoned Majid to talk with him about this, but he reacted defensively. Kate realized that he took her suggestion to mean that he was not sufficiently fluent in English or that he could not represent
Mouna's views fairly. Kate explained that neither was the case, but rather that she wanted Majid to feel free to express his own concerns without the pressure of needing to attend to Mouna's needs simultane- ously. Majid finally agreed to an interpreter on one condition—that he know the name of the person beforehand to be sure that they were not in the same social circle, the Tunisian community in their city being rel- atively small. He and Kate agreed on a Lebanese woman who spoke Arabic and did interpretation for a large hospital. Before their next assess- ment session, Kate talked with the interpreter on the telephone, asking questions about her expertise, confirming her understanding of confi- dentiality, and generally establishing rapport.
During her consultation with the Arab American therapist, Kate described her impressions of Mouna and Majid and mentioned their arranged marriage. The consultant sensed some judgmentalism on Kate's part and explained that arranged marriages are still common in Tunisia and that they help to ensure that families as well as individuals are well matched. She added that divorce is relatively uncommon. Her comments challenged Kate to think further about her assumptions regarding arranged marriages.
Kate also expressed concerns about the impact on Mouna and Majid of current political events. She said that she had not been sure of whether to ask about this, so she refrained, but at the same time she did not want them to think that she agreed with the U.S. government's actions in Iraq. The consultant validated Kate's wish to be respectful but said that given the pervasiveness of anti-Arab and anti-Muslim senti- ment and its possible effects on a person's mental health, this topic was an important cause of stress to consider. The consultant explained that in addition to the U.S. invasion of Iraq, Kate needed to consider an ongoing series of events affecting Arab and Muslim people. She named the U.S.-led coalition against the Iraqi invasion of Kuwait during the Gulf War that resulted in the deaths of thousands of Arab people, the abuse of Arab Muslim prisoners by U.S. soldiers at Abu Ghraib, the ongoing U.S.
support of Israel over the Palestinians, and the U.S. supply of weapons to Israel during the latter's bombing of Lebanon in 2006. She added that fol- lowing the attacks on the World Trade Center, hate crimes in the United States against Muslims and Arab people increased dramatically (Zogby, 2003). The consultant explained how all of these actions, on top of a his- tory of negative stereotypes and prejudice against Arabs and Muslims, could contribute to feelings of anger, frustration, distrust (i.e., of Amer- icans), and hopelessness among Arab and Muslim people.
The consultant suggested asking Mouna and Majid, "Have you expe- rienced discrimination or racism during your time here in the United States?" as part of the assessment of chronic and acute stressors in the couple's lives. She said that if Mouna or Majid did not want to talk about this, Kate would probably sense it from their responses, and she could
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refrain from further exploring the topic until trust was more firmly established. (Muslims and Arab people may be slow to disclose informa- tion related to religion or politics until trust has been established; All et al., 2004; Erickson & Al-Timmimi, 2001.)
The consultant also called Kate's attention to the assumption embed- ded in Kate's statement that she did not want Mouna and Majid to assume that she agreed with the U.S. government's actions. The consultant told Kate that although it was likely (considering the couple's more recent immigration, Majid's strong Muslim identity, and the current political climate) that the couple disagreed with U.S. policies, it was also possi- ble that they did not. The consultant explained that although more recently immigrated Arabs and Muslims tend to be less satisfied with U.S. foreign policy, up until the 1980s the majority of Arab Americans were Republican and tended toward assimilation into the dominant cul- ture (Erikson & Al-Timmimi, 2001). The consultant reminded Kate that there can be just as much diversity in the way Arab and Muslim people see the world and themselves as there is between ethnic and religious cultures. She encouraged Kate to continue her reading and look for community events at which she might meet a wide variety of Arab and Muslim people.