he could to help her: He took her out as much as possible and encour- aged her to take more English classes. He was starting to worry about their ability to have a baby, and he was beginning to think that she might have some sort of physical problem.
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context. However, she understood that although she was there to help this couple consider possible new behaviors and views, she would need to be careful not to impose her own beliefs regarding relationships and men's and women's roles.
Majid's Identity
Although Majid's identity was as firmly connected to his culture and fam- ily of origin as was Mouna's, the meaning of this connection was quite different. Majid was not from a Tunisoise family; the lower social class and the strict religious practice of his family set them apart from Tunisian soci- ety's more secular ideal of the 1960s and 1970s, just after independence from France. Even before he moved to the United States, Majid had felt
"different."
Through his family, Majid had developed a deep sense of himself as a religious and spiritual person. Although nearly all of the Muslims he met growing up were Tunisian, his parents taught him to think about Muslims around the world as one community. After arriving in the United States, he attended a mosque for a few years and was delighted to meet Muslims who were Cambodian, Indonesian, Nigerian, and African American.
Majid identified himself primarily as a Tunisian man; however, dur- ing his 14-year residence in the United States, he had learned that most Americans know little if anything about Tunisia. Thus, when describing himself to Kate, he added information that he would not have added for a Tunisian listener (e.g., that he was Arab and Muslim). Although he did not specifically refer to himself as a member of an ethnic minority culture in the United States, his experiences had led him to identify with diverse people of color rather than with the European American majority.
With regard to his expectations and beliefs about marriage and the influence of gender, Majid's point of reference was a melange of Tunisian, Muslim, and American influences. He described his belief in the equal- ity of men and women and his marriage as an egalitarian relationship in which he and Mouna should "support each other to be good people and to do our best." From his years of living alone, he was used to cook- ing and cleaning up after himself, although Mouna always made din- ner now. He wanted Mouna to make friends and return to working outside the home again, even after having children, if that would make her happy. He assumed that he would be the primary breadwinner but imagined that once Mouna was fluent in English, she would manage their money, as his mother had in his family. Since their marriage, he had tried to make important decisions in collaboration with Mouna (e.g., about decorating the apartment, where to go on outings, planning for the future), and he expected that she would start driving once her English was sufficient to pass the driver's test. Table 8.2 summarizes the salient ADDRESSING influences in Majid's life.
T A B L E 8 . 2
Cultural Influences in Majid's Life
Cultural influences Details
Age and generational influences
Developmental disabilities Disabilities acquired later in life Religion and spiritual
orientation
Ethnic and racial identity Socioeconomic status
Sexual orientation Indigenous heritage National origin Gender
34 years old; born in 1973; middle child of three. Majid was in an early generation of boys educated after independence for whom expectations of success were extremely high. His generation expected to live a secular lifestyle, but Majid was not brought up this way.
None reported or apparent None reported or apparent
Parents both practicing Muslims; Majid has a deep sense of himself as a religious and spiritual person, although not currently practicing.
Mother and father both Arab Tunisian; Arabic is spoken in their home; Majid is fluent in French and English, too.
Parents had elementary school educations and were working poor; family lived in Tunis but was not Tunisoise.
Probably heterosexual None
Tunisian; living as a permanent resident in the United States; has considered obtaining U.S. citizenship as well.
Male; middle child but youngest son; newly married, with a strong desire to be a "good husband" (meaning in an egalitarian, mutually supportive relationship, as primary breadwinner); no children, but has expectations of fatherhood as central to his life and identity as a man.
CASE CONCEPTUALIZATION AND DIAGNOSIS
With this understanding of the salient cultural influences on Mouna and Majid, Kate was in a position to consider what would be the most accurate and useful conceptualization and diagnosis for their case. She was knowledgeable enough about the stressors involved in immigration to realize that Mouna's depressive symptoms (crying, excessive sleep- ing, sad mood and affect) are common responses to the enormous changes involved in such a transition. She understood how Mouna's accultura- tion difficulties might be exacerbated by the current political climate and racism in the dominant culture. Thinking systemically, Kate also recognized the adjustment difficulties that Majid was experiencing as a result of the marriage and his new role as a husband. And from the con- sultant, she learned that a huge missing piece in the adjustment of both Mouna and Majid was the social support from extended families that they would have received as a newly married couple in Tunisia.
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Majid's distress did not meet criteria for a DSM-IV-TR diagnosis. For Mouna, the V code Acculturation Problem was clearly justified, but the question remained whether this would be a sole, primary, or secondary diagnosis. Mouna's symptoms suggested the possibility of a Major Depressive Episode or Adjustment Disorder With Depressed Mood. Kate ruled out the first diagnosis because Mouna did not report at least five of the required symptoms, but the decision to rule out an Adjustment Disorder was more complex.
Diagnosis of an Adjustment Disorder requires the development of
"clinically significant emotional or behavioral symptoms" (p. 679) within 3 months of the onset of a stressor (APA, 2000). The symptoms or behav- iors must be "in excess of what would be expected given the nature of the stressor" or result in "significant impairment in social or occupational (aca- demic) functioning" (p. 679). Immigration and discrimination qualify as stressors (or more accurately, a collection of stressors), and Mouna's symp- toms had begun within 3 months after her move. However, her distress was not in excess of what one would expect in the face of such a transition.
The difficult question was deciding whether or not her symptoms were significantly impairing her social, occupational, or academic func- tioning. Mouna was not impaired in her ability to relate to people or to form new relationships; she simply lacked opportunities and was limited by the language barrier. She continued to carry out most of her house- hold responsibilities (although she no longer cooked breakfast), and she was progressing in her English class. However, one could argue that her depressive symptoms were interfering with her marital relationship.
With this information in mind, Kate chose to conceptualize the case as one in which extraordinary stressors were affecting both Mouna and Majid individually and in their relationship as a couple. Mouna was clearly more expressive of her distress and thus more easily seen as "the patient." Her symptoms were marginally diagnosable as an Adjustment Disorder. In an ideal world, Kate noted to herself, she would not diag- nose Mouna so as to avoid pathologizing her. However, in their current situation, the managed care company would pay only for treatment of a clinical or personality disorder (i.e., not for a V code such as Accultur- ation or Partner Relational Problem). In addition, Kate suspected that Mouna and Majid would not return if their insurance did not cover the therapy. (See Cooper & Gottlieb, 2000, and Eisman et al., 2000, regard- ing reimbursement and ethical issues related to managed care.)