Chapter 1

Biopsychosocial Perspectives on Arab

Americans: An Introduction

Sylvia C. Nassar-McMillan, Kristine J. Ajrouch, and Julie Hakim-Larson

For centuries, the mind–body connection has been debated. While perhaps associ-
ated more with an Eastern vs. Western worldview, the concept of the mind and body
as intimately intertwined has waned in and out of popular discourse throughout
human civilization. Arguably, corresponding with the World Health Organization’s
initiatives to define integrated health services (2008), efforts toward evidence-based
treatments and practices have been reported with greater frequency over the past
decade or so. These efforts have included scholarly inquiry into contemporary mod-
els of integrated, or collaborative care, wherein the focus is on the whole person,
administered collaboratively between teams comprised of physicians and mental
health counselors (Glueck, 2012; Miller, Mendenhall, & Malik, 2009).
The biopsychosocial model of care is one in particular that has been given atten-
tion in the scholarly and medical bodies of literature recently, including in the Arab
world (e.g., Nasir & Abdul-Haq, 2008). Credited to Engel (1977), this approach
suggests that while the biomedical model may explain the root causes of health
issues, psychological variables, demands on life, and social and cultural conditions
may just as likely impact the course of any disease progress, be it physical or mental.

S.C. Nassar-McMillan (*)

Department of Curriculum, Instruction, and Counselor Education,
North Carolina State University, 2310 Stinson Drive, Poe Hall 520, Campus Box 7801,
Raleigh, NC 27695-7801, USA
e-mail: snassar@ncsu.edu
K.J. Ajrouch
Department of Sociology, Anthropology, Criminology, Eastern Michigan
University, 712 Pray-Harrold, Ypsilanti, MI 48198, USA
e-mail: kajrouch@emich.edu
J. Hakim-Larson
Department of Psychology, University of Windsor, 401 Sunset Avenue,
Windsor, ON, Canada N9B 3P4
e-mail: hakim@uwindsor.ca

S.C. Nassar-McMillan et al. (eds.), Biopsychosocial Perspectives on Arab Americans: 1

Culture, Development, and Health, DOI 10.1007/978-1-4614-8238-3_1,
© Springer Science+Business Media New York 2014
2 S.C. Nassar-McMillan et al.

Center for Disease Control research on this topic at national levels in the USA has
empirically validated this notion by showing that unhealthy lifestyles and behaviors
lead to chronic illness and, conversely, that early intervention targeting such behav-
iors demonstrate improvements in a variety of health outcomes (Chiu & Wray,
2010; LaRowe, Wubben, Cronin, Vannatter, & Adams, 2007; Merrill et al., 2008).
Within the USA in particular, the medical model has been the predominant vehi-
cle for delivery of health care for quite some time, despite the 1948 call for a more
integrated approach to providing health care. The landmark legislation, in the form
of the Affordable Health Care Act enacted in June 2012, is the first of its kind in the
USA to mandate that prevention screenings and treatment for mental disorders,
including substance abuse, be incorporated into medical care (Glueck, 2012; United
States Department of Health and Human Services, 2011).
While perhaps more recently embraced by the medical field, mental health
practitioners across a variety of settings and disciplines have employed the biopsy-
chosocial model in their work for several decades. In addition to the presenting
problem, typical clinical intake sessions include questions about developmental
history over the lifespan, education and occupation, family of origin, social support,
and religion. More comprehensive assessments may also consider historical and
current substance abuse, mental health, and legal status in addition to medical
issues. While categories such as family of origin and social support, among others,
could certainly include cultural factors, culture itself is not typically articulated as
a descriptor within this approach. Mental health clinicians, particularly those within
rich ethnic communities and those otherwise more highly attuned to the potential
impacts of culture on mental health, often talk about the importance of attention to
this issue and may personally advocate for the inclusion of culture within initial
client assessment as well as ongoing treatment. Including a “cultural lens” to a
biopsychosocial approach to health was recently introduced (Jackson, Antonucci,
& Brown, 2004), to suggest that cultural distinctiveness—that is, specific behav-
iors, attitudes, beliefs, and values—serve as resources and contribute in complex
and significant ways to health and well-being. Associated with culture are matters
of stratification that occur because of racial or ethnic affiliation, suggesting that
attention be drawn to historical context and structural position as they relate to
members of specific racial, religious, and ethnic groups. These issues are critical for
health professionals to understand in the delivery of care. Recognition of culture in
health care delivery appears to increase not only the effectiveness of such service in
cost-effective ways but also contributes to a more complete understanding of the
health status and health needs of persons more generally (Jackson et al., 2004). It is
this stance that we attempt to convey in the present text. We weave together, through
the book’s major sections, salient factors of culture, development, and health, sup-
porting the notion that these dimensions are inextricably related, particularly for
Arab Americans. The full structure of the book and chapters are reviewed at the end
of this Introduction, but first we will provide an overview of some of the more
undergirding issues that will be found throughout the text. Beginning with immi-
gration history as a backdrop, we will describe some basic information about the
immigration of Arabs to the USA, define some key terms related to that
1 Biopsychosocial Perspectives on Arab Americans 3

immigration history, and identify critical incidents in the context of immigration

and their implications for research, practice, and policy, along with their potential
influences on assimilation and ethnic identity of Arab Americans. Finally, we will
briefly overview the rationale and thematic undergirding for each of the three sec-
tions, as well as the chapter topics and their structure. As in any edited text, the
richness of the material is enhanced by the diversity of authors and their respective
perspectives. We hope you will find this even more to be the case in our holistic
approach, vis-à-vis the biopsychosocial model, as well as the corresponding inter-
disciplinary nature of the overall text.

Immigration History

Several of the chapters, particularly those in Part I, will detail comprehensively the
immigration waves of Arabs to the USA. As a reader, you may notice discrepancies
among the various chapters in terms of the number of waves that are cited, as well
as among countries of origin or time periods identified. Most scholars cite anywhere
from two (e.g., Suleiman, 1999) to four (e.g., Nassar-McMillan, 2010) primary
waves of immigration from the Arab world to the USA. The wide range of countries
represented by this immigration also may serve to complicate this dynamic even
more. For example, scholars focusing on immigration specifically from Lebanon, or
Iraq, or any number of other countries (i.e., virtually any country in question), might
identify a somewhat different wave based on the uniqueness of immigration from
that country or region, often based on a country- or region-specific critical incident
or incidents, such as the civil war in Lebanon in the 1970s or the Gulf War in Iraq
in the early 1990s. Following are, generally stated, the various waves of immigra-
tion that have been cited in the literature over the past several decades:
• 1400s—Arabs accompanied Columbus and Spanish settlers to the New World
(Arab American National, 2013).
• 1500s—millions of Arabs with origins in African countries were brought to the
USA as part of the slave trade. Because their names were changed during that
process, immigration and lineage for this group of immigrants is difficult to track
(Arab American National, 2013).
• 1880s–1920s—the first waves are said to have come as part of the Great
Migration, joining immigrants from countries worldwide in search of better eco-
nomic opportunities. In many cases these Christian Arabs were fleeing the vast
Ottoman (i.e., pan-Islamic) Empire (Orafalea, 2006).
• Post-World War II—often referred to as the Brain Drain, these Arab immigrants
came to the USA to escape political tensions in their region. This group was
primarily Muslim and well educated (Orafalea, 2006).
• 1960s—this group, like its immediate predecessors, was predominantly educated
and Muslim; with reason for immigration to the USA being economic opportuni-
ties, opened up by loosened immigration restrictions; many were also unhappy
with the continued political strife in the region (Orafalea, 2006).
4 S.C. Nassar-McMillan et al.

• 1970s–1980s—Civil War and Israeli invasion of Lebanon prompted large

numbers to leave Lebanon for the USA via chain migration (Samhan, 2014).
• 1990s—the Gulf War caused an Iraqi refugee crisis, with US President George
W. Bush agreeing to allow refugees who had supported the USA to immigrate to
the USA (Samhan, 2014).
• 1990s and beyond—refugees and immigrants from the Arab Middle East con-
tinue to immigrate to the USA for various reasons.
• September 11, 2001—the Twin Tower, New York City bombings and the subse-
quent War on Terror and its corresponding long-term occupation of Iraq by the
United States, have provided a context for continued immigration from the Arab
Middle East, most notably from Iraq (United States Citizenship and Immigration
Services, 2012).
In many cases the USA is a key player in the political situations indirectly or
directly leading up to the immigration. One example of this interaction is the Gulf
War, as a result of which many Iraqis who fought on the side of the USA fled or
otherwise immigrated to the USA and other countries for safety-related reasons
(Jamil, Nassar-McMillan, & Lambert, 2007; Jamil, Nassar-McMillan, Lambert, &
Hammad, 2007; Nassar-McMillan, Jamil, & Lambert, 2010). A second is the
US-initiated War on Terror and the US occupation of Iraq mentioned above. It
remains to be seen how the USA will become involved in the Arab Spring move-
ments across the Arab Middle East and whether and how that involvement will
interact with the US immigration policies and trends.

Key Definitions

The terms Middle Eastern and Arab American have historically been utilized inter-
changeably across various bodies of literature. A simple Internet search for maps of
the Middle East yields vastly different portrayals of this region (e.g., Google, 2013;
University of Texas Libraries, 2013; WorldAtlas, 2013), with many covering coun-
tries that do not define themselves as Arab (e.g., Turkey, Iran). Thus, geographi-
cally, the Middle Eastern region spans countries that are clearly non-Arab, such as
Afghanistan, Pakistan, Turkey, Israel, among others. Other entities have defined
Arab countries, or individuals of Arab descent, as being from Arab-speaking coun-
tries (e.g., de la Cruz & Brittingham, 2003). Still others, and this is by and large the
perspective of the chapter authors in the present text, link the terms Arab or Arab
American with origins from the countries belonging to the League of Arab States.
These 22 countries are Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan,
Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi
Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. Despite
the variety in defining Arab American, many scholars of multiculturalism agree that
key in the distinction is the individual or groups’ self-definition or identification
(Samhan, 1999, 2014).
1 Biopsychosocial Perspectives on Arab Americans 5

One additional point that needs to be noted here is the recent emergence of the
term Middle Eastern/North African (MENA). While we applaud the domestic and
global communities for their earnest efforts to understand and give credence to
issues unique to these regions and those with ancestry from them, we have concerns
that have not yet been fully explored related to this relatively recently emergent
umbrella term. As can easily be interpreted, the regions inherently identified by
MENA (i.e., Middle East and North Africa) or other relatively new synonymous
terms such as WANA (West Asia/North Africa) or NAWA (North Africa/West Asia)
exclude multiple Arab League States. While the World Bank’s establishment of the
MENA term might be fiscally appropriate on a global level, it falls short in its appli-
cation of clarifying and defining a population that has, particularly in recent decades,
striven hard to create a unifying self-definition. To that end, we avoid the term and
caution readers not to conceptualize Arab Americans as being fully synonymous
with those of MENA descent. In this text, the most likely terms to refer to our popu-
lation of interest are Arab American or individuals of Arab descent.
A final distinction that needs to be made and will indeed be made further salient
in the following chapters is the religious diversity among Arab Americans. As can
be explicated from the key immigration points identified above, it is not accurate to
assume Arab and Muslim as synonymous terms. In fact, because the late nineteenth-
century wave of immigration was predominantly Christian, the majority of Arab
Americans today are Christian, or at the very least, non-Muslim. Even today, the
many refugees and immigrants from Iraq represent Iraqi Christians (called
Chaldeans or Assyrians), along with their Iraqi Muslim (Shiite, Sunni) counterparts
(Samhan, 2014).

Critical Incidents: 9-11, the Palestinian-Israeli Conflict,

and the Arab Spring

Although the upcoming chapter on sociopolitical history will include all of the rel-
evant critical incidents characterizing the relationships between the USA and vari-
ous countries and regions within the Arab Middle East, one key incident is worthy
of note here. The tragedy of the bombing of New York City’s Twin Towers that
occurred on September 11, 2001, caused a resounding impact, built upon already
uneasy foundations. That fateful event set off a series of events that still strongly
reverberate more than a decade later. As many Arab Americans will recount, any act
of terror, whether on domestic or international soil, instills immediate fear and con-
cern over retaliation toward Arab Americans or the Arab Middle East, regardless of
the perpetrator’s ethnicity. This emotional response clearly has the potential for
impact upon an individual or groups’ ethnic identity. In some cases, it may heighten
ethnic identification, while in others may cause individuals to strive for invisibility
within society at large.
In any case, the 9-11 bombing indirectly lead to a US-based invasion of Iraq,
along with a subsequent decade-long occupation by the US military troops. Clearly,
6 S.C. Nassar-McMillan et al.

this is a salient issue among Arab Americans, as it is within the mainstream USA.
Although these circumstances may have served to somewhat mask the decades-
ongoing Israel-Palestine conflict, this issue also remains one of critical importance
for Arab Americans (Arab American, 2013). Finally, the Arab Spring movements,
ranging from minor civil unrest to major protests and governmental overthrows
occurring across the Arab Middle East since December 2010, have clear implica-
tions for public relations between that region and the USA, with public opinion
toward the USA in some countries there polling in at record lows (Zogby, 2010).
Present day empirical inquiry has only just begun to examine the tip of the ice-
berg represented by these issues and their impacts on individuals’ ethnic identities.
While various authors will discuss terms such as ethnic identity and assimilation
(often-corresponding terms), it should be again noted that the interdisciplinary
nature of the scholars across and even within book sections may serve to approach
these terms from new or unique and sometimes seemingly disparate discipline-
specific perspectives.

Thematic Undergirding and Chapter Structure

Although the present text is intended to provide a comprehensive biopsychosocial

view of Arab Americans and their health care, each section can be influential in its
own right as a stand-alone text of sorts. As previously mentioned, each section, and
indeed chapters within each section, represent a diverse array of disciplinary back-
grounds among chapter authors, as well as section-specific thematic undergirding.
Each section examines the overall salience of assimilation and ethnic identity issues
with different manifestation foci.
Part I provides societal context and examines outcomes from a corresponding
social relations perspective. Chapters in this section, authored by prominent
sociologists and scholars in closely related fields, include topics of sociopoliti-
cal history; intra-ethnic diversity and religion; gender; family traditions and
values; the aging process; and culture, forgiveness, and social relations. Part II,
with its prominent developmental focus, examines personal and developmental
contexts and corresponding outcomes. Authors in this section span various clin-
ical mental health fields and include both scholar and clinician perspectives.
Part II chapters include topics of acculturation, ethnic identity, and gender; Arab
refugees; mental health risks; education and employment; and environmental
health. Finally, Part III blends together overall physical and behavioral contexts
and examines epidemiological and mitigating factors within both context and
outcome perspectives. This section’s author teams include academic and clini-
cal professionals. Part III includes topics of substance abuse, diabetes, maternal
and childhood health, cancer, and advocacy needs for the Arab American com-
munity nationally. Finally, the book concludes with a synthesis chapter, clearly
discussing implications concerning the need for prevention efforts at local,
national, and international levels.
1 Biopsychosocial Perspectives on Arab Americans 7

Across sections, readers will find the same, or similar, basic elements within
each chapter. These include an introduction to the chapter topic; historical back-
ground and context, sometimes referring to historical regions of origin; relevant
theoretical constructs; methodological approaches and their critiques; and implica-
tions for practice, research, and policy. Although the rationale for our biopsychoso-
cial approach was introduced in this Introduction, along with our perspective of the
need for culture to be more clearly articulated within the overall assessment across
diverse client or patient settings, one final point of note in our perspective is the
need for interdisciplinary professionals to impact policy change. While implications
for research and policy might be inherently obvious within the sociological domains
(and hence, Part I chapters) and implications for research and practice more clearly
applicable within clinical domains (spanned by Parts II and III chapters), our view
is that an advocacy role is inherently prescribed within an overall effective biopsy-
chosocial approach. This relatively newly emergent role spans multiple health and
mental health disciplines in its development as well as in the multidisciplinary per-
spective of its criticality and urgency.
In 2002 the American Psychological Association approved as policy a set of
guidelines, namely, the Guidelines on Multicultural Education, Training, Research,
Practice, and Organizational Change for Psychologists. This document details six
domains relevant to culturally appropriate psychology practice, ranging from cul-
tural knowledge of self and others coupled with multiculturally relevant responsive-
ness, to the importance of and need for employing constructs of culture across
education, research, and clinical practice (American Psychological, 2002). Lastly, it
cogently calls for scholar-practitioners to facilitate organizational change through
culturally relevant policy development and practice. This latter component is
embodied in the final Guideline and is particularly salient for work with Arab
American populations (Nassar-McMillan, 2007).
Many clinicians and scholars alike may view themselves as apolitical.
Implications for policy within the contemporary interdisciplinary literature at large,
paralleling our own textbook’s structure, are limited somewhat typically to the
enhancement and efficacy of relevant research and corresponding evidence-based
practice. These pleas represent critical precursors to the striven-for levels of recog-
nition in the immediate domains (e.g., aging research, clinical interventions with
refugees or diabetic patients) that likely impact clients’ mental and physical health
and well-being. At the same time, they are in and of themselves insufficient to
change the ways in which society at large views the issues at hand. In other words,
attention to the larger context within which people live includes political dynamics
that influence the status, resources, and constraints experienced by various popula-
tions, including Arab Americans. Without appropriate legislation and policy change,
the status of Arab Americans in terms of acculturation, mental health, and wellness
is not likely to change (Nassar-McMillan, 2007). Thus, we make the case that
broader, sweeping issues such as discrimination and violations of civil liberties have
direct and indirect impacts upon the well-being of Arab Americans. And that, while
our attempts in this text encompass a holistic and comprehensive perspective to
assessment and treatment, true prevention must strive to eradicate the root causes of
8 S.C. Nassar-McMillan et al.

illness altogether. With that said, this edited volume challenges each and every
scholar and clinician committed to the well-being of all people, to advocate for and
support constructive changes at political levels beyond even the intuitively broad
and comprehensive biopsychosocial approach whenever possible. In doing so, the
resulting domestic and foreign policy changes will ultimately lead to a healthier and
safer global context for all individuals.

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