American Muslims, mosques, and mental healthcare

“There are symbolic places that awaken memories whether you mean to or not.”
-Dalil Boubakeur, head, Grande Mosquee of Paris

As loud as has been the discussion about Muslims in America and the Middle East ever since 9/11/01, as quiet has been the discussion about Muslims and mental healthcare. Most recently, of course, the controversy about building a Muslim community center near “ground zero” in Manhattan has reached shouting levels. Reminders of legal rights versus cries of cultural insensitivity abound. In other parts of the country, related controversies have erupted.

Over the same time, discussion of mental healthcare of American Muslims has been quite sparse in the psychiatric literature, especially in comparison to other prominent ethnic and religious cultural groups. I wonder why. Has that been because they received good care? Or, was their religious and/or ethnic background not known or even ignored? Or, did they come less to mainstream psychiatric facilities? Or, is the issue felt, consciously or unconsciously, to be “too hot to handle”?

I have long specialized in cultural aspects of psychiatry and received numerous grants for refugees. Muslims I have treated have included refugees from Somalia, immigrants from the Middle East, and Black American religious converts. We have tried to provide competent care for them and other groups that tended to be underserved or mis-served, using information on their cultural values supplemented by the unique perspective of each patient.

Other anecdotal experiences of colleagues, sparse as it seems to be, imply some special cultural considerations for American Muslims (or, Muslim Americans, depending on what one prefers in terms of terminology). Most note that trust is a large hurdle. In countries outside of the USA, privacy was rare, with the common anticipation that confidentiality would also be violated here. For similar reasons, the patient may prefer a clinician who is not Muslim and/or does not speak Arabic. Distrust can also be more intense if a Muslim clinician is from a different tribe or denomination than the patient.

On the other hand, the modesty of more traditional Muslim women will require them to not be alone in the office of a male clinician. If a patient believes in the Jinn spirits, a non-Muslim clinician may not understand what that may mean.

Yet, having all that knowledge and experience, and knowing better, here I am, beginning to wonder if the quality of my care of American Muslim patients was deteriorating recently. I became more irritable when patients asked for medication adjustments for Ramadan. Why didn’t I more readily prescribe a stimulant skin patch instead of oral medication? Countertransference mistrust? But why didn’t they ask me earlier? Transference mistrust? Though we rarely talked about our religious differences, there were clues in my office as to my background. Whatever the reasons, I wasn’t living up to the “I-Thou” ideal I recommended in my last blog. I must apologize when I see them next.

The first rule of cross-cultural psychiatry is cultural sensitivity. Maybe I was becoming as insensitive as those who planned a building so close to an emotionally provocative area. If built, there would invariably be triggers to the 9/11 trauma for those significantly affected, yet Muslims could take the controversy as a rejection, locally, nationally, and internationally, thereby escalating anger in the more radical.

Time magazine recently (8/30/10 issue) had a cover story on the question “Is America Islamophobic?” First of all, one has to wonder if it is appropriate to adapt a clinical term like phobia to a cultural group. I know it was done before in terms of “homophobia.” I also don’t think that phobia applies very well. Not only does such expression of anger rarely occur in clinical phobias, but the fear of something like 9/11 happening again may not be irrational.

If we need to adapt a clinical reference, Posttraumatic (9/11) Stress Disorder seems to fit better. Whenever any Muslims do something that reminds the rest of us of 9/11, it may act as a trigger to the prior trauma. If so, the “treatment” might be an educational version of Cognitive Behavioral Therapy, whereby our leaders point out the distortions in current thinking and model appropriate behavior. It may be reassuring to matter-of-factly point out (while “knocking on wood”) that there has been no significant terrorist attack within the USA since 9/11/01.

Emotionally complicating this year’s 9/11 anniversary is the closing feast of Ramadan, starting 9/10 or 9/11 (depending on the moon). The most significant Sabbath on the Jewish calendar, which is the Saturday between the New Year of Rosh Hashanah and the Day of Atonement, Yom Kippur, is 9/11/10. Talk about a triple bewitching date! Then, next year, we have the major symbolic 10 year anniversary to prepare for on 9/11/11.

Should we in behavioral healthcare take more part in these societal discussions and deliberations? Or, should we just tend to our own house with more study and research about providing mental healthcare to American Muslims?

I can do better. Can you do better? And, the nations of the world must do better cross-culturally if we are to reduce global threats, whether that be from climate instability, nuclear war, terrorism, or mental illness. We must overcome the biological and political tendency to fear, scapegoat, and stigmatize the “other” in favor of a more global identification and respect.

Shalom and Salam.