Keywords

Pre-migration, migration, and post-migration issues are all relevant ones to consider in fostering the overall health and well-being of Arab families in North America whose origins are from the Levant region of the Middle East. The Levant region includes the modern-day countries of Syria, Lebanon, and Israel/Palestine (Mansel, 2010), as well as some regions of western Jordan (BibArch, 2013). The inhabitants of this region have a wide diversity of backgrounds, and Eastern or Levantine Arabic is only one of the many languages spoken. The focus of this chapter is on Arab people who speak the Levantine or Eastern Arabic dialect (El-Baz, 1968), a group whose members have been immigrating to North America for more than a century.

We have used a bioecological approach to provide an overview of the microsystems and macrosystems relevant for the adaptation of Levantine Arab families to North American life. Racism, discrimination, and prejudicial attitudes, prevalent historically, have extended into contemporary times. Historically, pre-migration wars and conflicts influenced the immigration patterns to North America; thus, the demographics of five waves of immigration to North America since the late nineteenth century are summarized. Following next are discussions of the stress of acculturation to the United States and Canada and socialization to foster enculturation and preservation of the heritage culture. A presentation of religious and family values is followed by sections that address gender roles, intermarriages, and educational and career achievements. Finally, we consider implications for the mental health and adaptation of families from the Levant and future directions for research and practice.

Bioecological Theory and Levant Families

Taking a bioecological approach to human development (e.g., Bronfenbrenner, 1994; Bronfenbrenner & Morris, 2006), it becomes apparent that sociopolitical issues have direct relevance for the mental health and well-being of immigrant families who may be stressed by both historical memories and ongoing turmoil. For example, Phillips and Lauterbach (2017) highlighted the importance of examining the mental health of American Muslim immigrants, many of whom are from the Levant region, through a transactional model such as Ecological Systems Theory (Bronfenbrenner, 1994). They proposed examining interactions between microsystem and macrosystem variables with respect to racism, mental health, and mental health stigma as experienced by American Muslim immigrants.

Microsystem and Macrosystem Racism

Microsystem racism corresponds to discrimination within settings such as home, school, and the workplace and has been found to be associated with poor mental and physical health. Even though not all Arabs are Muslim (many are Christian, other religious denominations, or no religion) and not all Muslims are Arabs (most Muslims worldwide come from outside the Middle East), the terms ‘Arab’ and ‘Muslim’ are often conflated in North America (Suleiman, 1999). Thus, racism and discrimination towards one group often generalizes to the other. This overgeneralization has been especially likely to occur after the tragic events of 9/11, resulting in the two groups often being treated as one monolithic entity (e.g., Cainkar, 2016).

Consistent with the macrosystem generalized racial discrimination , American Muslim immigrants with mental illness tend to be especially prone to mental health stigma and aversive interpersonal interactions (e.g., Phillips & Lauterbach, 2017). Discrimination toward Arab Americans more generally has been linked to increases in their psychological distress (Awad & Amayreh, 2016). In addition, children in U.S. elementary schools have been found to hold stereotypes and prejudicial views about Arab Muslim immigrants as compared to Arabs without clothing that indicates they are Muslim and White families from Ireland (Brown, Ali, Stone, & Jewell, 2017). In the Brown et al. study (2017), children ages 6–11 years in the United States read three vignettes about immigrant families. They found that the children viewed Arab Muslim males as anti-American and perceived Arab Muslim females as more oppressed than the other groups, and this was particularly the case for those who had limited contact with Arab Muslims. When children did not distinguish Arab Muslims and the American in-group, they had a more positive attitude toward Arab Muslims who immigrated to the United States in the vignette.

Macrosystem racism includes ideological and institutional racism and captures the systemic oppression associated with factors such as socio-economic status, resources, and employment, all of which are associated with mental health outcomes (Phillips & Lauterbach, 2017). Scholars have noted that even though Arab Americans tend to be better educated than the general American population, they may nonetheless experience racism, discrimination, social injustices, disparities, and intolerance (Arab American Institute, 2017). While macrosystem racism has a distal influence on Arab immigrants, microsystem racism has more proximal and direct effects on everyday interactions at home, school and work through microaggressions and insults (Phillips & Lauterbach, 2017).

To better understand the contemporary sociopolitical climates for Arab families in Canada and the US where such macrosystem and microsystem racism occurs, a closer examination of the both pre- and post-migration pathways is needed to contextualize Arab families. The insights from sociohistorical landscape for Arab families may assist in finding ways to counteract discrimination and promote social justice and tolerance with the goal of promoting the adaptation and well-being of Arab families from the Levant.

Pre-Migration Influences and Immigration Patterns

The pan-ethnic term, Arab American which includes people from the Levant, is relatively new and arose in the 1970s due to the many socio-political changes and events occurring in the Middle East (Abdelhady, 2014). Arab Americans come from both northern Africa and southwest Asia and thus vary by race, religion, and country-of-origin; the common binding factor is the Arabic language and culture arising from their homelands in one of the 22 Arab League of States that extend from Morocco in the West to the Arabian Peninsula and Persian Gulf in the east (e.g., Samhan, 2001). A broad label given to the region is MENA, which stands for Middle Eastern and North African and includes the Levant, Arabic speaking countries, and Middle Eastern countries where Arabic is not the official language (e.g., Afghanistan, Iran). Given this heterogeneity, it is important to consider pre-migration influences on the well-being of families by specific country of origin, and region within country, whenever possible.

Taking into consideration sociopolitical history, of interest and concern is the fact that pre-migration individuals originating in the Levant region who are closer to the epicentre of regional conflicts and warfare tend to be impacted more profoundly by the traumatic events. Regions of the Levant have been sought after for their land, oil, water, and the coastline for trade purposes; the ensuing conflicts have thus devastated the region’s families and affected their local cultures for centuries (Abi-Hashem, 2006). During the multiple and ongoing wars in the Arab Levant, some people have rebelled and fought while remaining in their homeland, while others have fled and coped by leaving their war-torn country in search of safety, better economic opportunities, and a better life for themselves and their families (e.g., Naff, 1985). Immigration patterns from the Levant and from other Arabic-speaking regions of the Middle East have varied throughout history and include those who came directly to North America from their homelands for economic advancement, those who were attempting to escape wartime adversities, and those who incurred multiple displacements to other countries around the world (e.g., Europe, other countries in the Middle East, Africa) before finally settling in North America (e.g., Abdelhady, 2014; Hodes et al., 2018; Mowafi, 2011).

Arab immigrants have arrived in the United States in four major waves in recent history (Nassar-McMillan, Ajrouch, & Hakim-Larson, 2014) with a fifth wave that is current. In the first wave of Arab immigration to America in the late 19th and early 20th centuries, Arab ethnic communities or enclaves were settled in a variety of locations (e.g., Cedar Rapids, Iowa; Detroit, Michigan); these immigrants supported their families primarily as peddlers or as laborers in industry (e.g., factory workers) (Naff, 1985). This first wave of Arab immigration occurred from the 1870s to the mid-1920s and consisted primarily of families from Greater Syria (Syria, Lebanon, and Palestine) (Haboush & Barakat, 2014). These people were of Semitic origin and descended from the indigenous inhabitants of the region extending back to the Neolithic period (Nydell, 2006). The Levantine people from this initial wave were mostly Christian non-professionals (farmers, peddlers, shopkeepers, and laborers) in search of a better life trying to escape the Ottoman occupation (Suleiman, 1999).

The second wave extended from post-World War II to the mid-1960s and included families from Palestine, Jordan, Egypt, Syria, and Iraq. They were primarily Muslim skilled professionals who were escaping war and civil conflicts in their countries of origin (Abdelhady, 2014). The third wave of immigration extended from the mid-1960s to the early 2000s and included primarily Muslim professional and non-professional immigrants from Palestine, Jordan, Lebanon, Egypt, Iraq, and Syria who were fleeing a series of civil wars and regional conflicts taking place in the Middle East (Suleiman, 1999).

The fourth wave of immigrant professionals and non-professionals has extended from the early 2000s to about 2011. This more recent wave not only included Arab families from the Levant but also those from other regions, such as Iraq and North Africa; their reasons for immigration included political instability and lack of economic opportunities in addition to wars (Haboush & Barakat, 2014). Immigration subsided only temporarily in the immediate aftermath of the September 11, 2001 attacks on the United States (Sue & Sue, 2008). Many immigrants from the Middle East have had extensive exposure to war and political unrest, have limited English language proficiency which affects their opportunities for work or further education, and have had to contend with discrimination in a post 9/11 era that included a number of changes in government policies (Haboush & Barakat, 2014).

A fifth wave of ongoing immigration is currently occurring worldwide. The Syrian civil war has led to historically unprecedented displacement of 13 million people (Connor, 2018). Since the beginning of the Syrian civil war around 2011, Syrians have either been internally displaced (more than 6 million or approximately 50%) or have had to flee; those who have fled their homeland have resettled in the Levant (e.g., Lebanon, Jordan), other countries in the Middle East (e.g., Turkey, Iraq, Egypt), in Europe, or various other countries around the world including Canada and the United States (Connor, 2018), as discussed further next.

Immigration of Syrian Refugees

Although the U.S. and Canada have both accepted some Syrian refugees as a result of the international crisis resulting from the Syrian civil war (ongoing since 2011), their histories and current policies differ. The Pew Research Center (Radford & Connor, 2019) conducted an analysis concerning resettled refugees in 2018 from the United Nations High Commissioner for Refugees and found that while nearly half of the world’s refugees in 2018 were from the Middle East, less than 1% of the refugees resettled in the U.S. were from that region; furthermore, in 2018 for the first time Canada resettled more refugees overall than the US. Policy changes in the Trump administration have led to a lower cap placed on the number of Arab refugees allowed into the US as compared to previous years (Radford & Connor, 2019). In addition, the overall number of refugees admitted to the US under the Trump administration progressively declined after 2016 (Krogstad, 2019).

Contrary to the current relatively open immigration policy in Canada, Arabs faced barriers to their admission to Canada and were considered among the undesirable immigrants prior to World War II. It was thought that the influx of Arab immigrants would have a negative impact on Canada’s Anglo-Saxon heritage and emphasis on White European culture (Abu-Laban & Abu-Laban, 1999b). These views began to change after World War II, and Canada began to liberalize its immigration policy for Arabs especially after 1967 (Abu-Laban & Abu-Laban, 1999b). A policy of multiculturalism was introduced in Canada in 1972 with the goals to avoid assimilation, increase intergroup harmony, increase intergroup contact and sharing, and encourage the learning of English and French (Berry et al., 2006). From 1990 to 1993, there was a great increase in Arab immigrants arriving in Canada who were fleeing the war in Lebanon (Canadian Arab Institute, 2013). Between January 2015 and May 2016, approximately 25,000 refugees from Syria resettled in Canada (Houle, 2019). Among those who were refugees from Syria, the majority were younger than other groups of refugees, and 85% were couples with their children. Demographic characteristics also differed between government-assisted refugees and privately sponsored refugees. As compared to privately sponsored Syrian refugees, government-assisted Syrian refugees tended to belong to larger families, were younger, had lower levels of education, and less proficiency in English or French. Over half of the refugees admitted into Canada in 2018 were from the Middle East (Radford & Connor, 2019).

Current Demographic Trends

Collecting information about the demographics of people from the Middle East and the Arab Levant has been challenging for researchers because these immigrants and refugees have been classified inconsistently and unreliably throughout history by their assumed race or another shifting category of classification; as a result, Arabs in the U.S. have often been described as an ‘invisible’ minority (Naber, 2000). Nonetheless, organizations such as the Arab American Institute in Washington, DC, continue to work towards collecting reliable information and estimates regarding Arab ancestry demographics.

The Arab American Institute (2019a) in the US estimates that there are approximately 3.7 million Americans with Arab ancestry. However, there are discrepancies between this estimate and the more conservative estimates arising from the ancestry question methods used by the U.S. Census Bureau, which have resulted in an undercount of the Arab American population. The U.S. Census Bureau (2018) used the results of the American Community Survey and estimated that there are at least 2.1 million Arab Americans in the U.S. Of the total number of Arab Americans in the U.S. in 2018, 496, 962 reported Lebanese ancestry (which is the largest subgroup of Arab ancestry in the U.S.), 192,497 reported a Syrian ancestry; 129,431 reported a Palestinian ancestry; and 95,937 reported a Jordanian ancestry (U.S. Census Bureau, 2018). In the United States currently, the majority of Arab Americans are descendants of the early immigrants who were primarily Christian, while Muslims represent the fastest growing segment of the Arab American community given recent immigration from the primarily Muslim Arab world after 1965 (Arab American Institute, 2019a; Arab American National Museum, 2009).

In the Arab world in general, there is a ‘youth bulge’ with the majority of people under 25 years of age (Harb, 2016). Arabs in both Canada and in the U.S. also are considered to be a relatively young group. Arab Canadians are considered to be among the visible minorities according to Canada’s Employment Equity Act. Among visible minorities, those of Arab ancestry represent the second youngest group, with a median age of 30.2 years, compared to 40.1 years for the entire Canadian population (Statistics Canada, 2011).

According to the results from the 2016 Canadian Census (Statistics Canada, 2016), 219,555 Canadians reported having a Lebanese origin; 44,820 reported having a Palestinian origin; 77,045 reported having a Syrian origin and 14,250 reported having a Jordanian origin. In 2016, Arabic was reported to be spoken by 629,055 Canadians, with 419,890 reporting Arabic as their mother tongue. It is important to take into consideration how countries have defined Arab immigrants. The U.S. Census Bureau’s definition of Arab ancestry is quite heterogeneous, as Arabs are described as individuals with ancestry originating from any of the Arabic-speaking countries of the world (de la Cruz & Brittingham, 2003). Unlike Canada, the U.S. does not officially recognize Arab Americans as a visible minority group. Noteworthy is the fact that obtaining accurate data is therefore quite difficult for researchers and practitioners because Arab Americans are counted among people who are designated as White or Caucasian, making them indistinguishable from European Americans in research, unless specific ancestry questions are posed (Samhan, 2014). Such specific ancestry questions are not included on the basic form that is sent to all families in the U.S. Census. There are pros and cons regarding the various potential methods of collecting census ancestry data, an issue that is currently being studied by the U. S. Census Bureau (Samhan, 2014), and is as yet unresolved (Arab American Institute, 2019b).

There has been a 76% increase in the number of people living in the U.S. with an Arab ancestry from 1990 to the 2006–2010 time period (Asi & Beaulieu, 2013). With each successive wave of immigration, there has been an increase in the number of Arab Americans. In addition, given that the first wave of immigration occurred at the turn of the late 19th and early 20th centuries, there are now an unknown number of third, fourth, and even fifth generation Arab Americans, many of whom continue to have informal ties to their ancestry through cultural traditions in their religious institutions and food preparations.

Arab Ethnic Identity: Acculturation and Acculturative Stress

For immigrants and refugees, maintaining an ethnic identity that allows them to retain their heritage culture while acculturating to their host culture is sometimes stressful and may lead to mental health challenges. Like other immigrant families, Arab Americans and Arab Canadians must adapt to their new environment by learning or improving on their use of the language(s) in their host culture and finding new emotional support systems (Nydell, 2006). Immigrants generally have to overcome barriers to their adjustment into the workforce, school systems, their neighborhood, and the legal systems in their new country of residence, all of which is quite stressful and this can be especially the case for younger recent Syrian immigrants, many of whom have parents facing acculturation challenges themselves (Hadfield, Ostrowski, & Ungar, 2017).

The pre-migration stresses for families from the Levant include their exposure to wars and its effects directly or vicariously on themselves, their family members, and their friends and acquaintances (Hadfield et al., 2017). During migration, many developed the status of ‘refugee’ and had to settle and resettle sometimes in places that were also war-torn geographical regions before eventually arriving in the US (Hakim-Larson, Kamoo, Nassar-McMillan, & Porcerelli, 2007). Another stressor is when the families’ preferred settlement location could not accommodate the family and thus, the family had to settle away from their relatives and friends (Hadfield et al., 2017). Exposure to torture and other forms of abuse and suffering before migrating can be cumulatively stressful and add to difficulties in coping and adapting during the post-migration acculturation process (Kira, Amer, & Wrobel, 2014).

For immigrants of Arab ancestry, post-migration acculturative stress is complicated even more by the issue of prejudicial feelings and overt discrimination post 9–11 (Ahmed & Mana, 2017; Awad, 2010; Nassar-McMillan, Lambert, & Hakim-Larson, 2011). To cope with this, children of immigrants may strive toward assimilation; thus, an acculturation gap may exist in which there is a discrepancy in the degree to which parents and their children adopt the values and customs of their new post-migration culture. This gap can lead to intergenerational conflicts and an exacerbation of post-migration difficulties involving ethnocultural identity development (Rasmi, Chuang, & Hennig, 2015).

Acculturation stress may be especially problematic for immigrants and their children who are Muslim due to their visibly noticeable religious dress. Amer (2014) and Awad (2010) found that Arab Americans who are Muslim in contrast to those who are Christian, may be more likely to be the subject of discrimination, and may therefore experience greater levels of acculturative stress. However, having a strong ethnic identity (i.e., identification with the heritage culture) and the support of one’s local Muslim community are likely to be protective factors. When Middle Eastern/Arab American adults have high religiosity and low to moderate levels of family connectedness, they are vulnerable to psychological distress associated with ethnic discrimination (Ikizler & Szymanski, 2017). Family connectedness, religious, and cultural factors have complex, and perhaps unique, relations to psychological distress among Middle Eastern/Arab Americans.

At a sociopolitical level, Muslim Arabs residing in North America where Judeo-Christian values and customs are normative, may be viewed with caution and skepticism in their communication and interpersonal interactions with those in the mainstream culture. This type of prejudice likely has implications for their adjustment and ethnic identity development (e.g., Britto, 2008; Britto & Amer, 2007), although additional research is needed to clarify the conditions under which it is likely to occur. Skin color and overt physical features in addition to religious dress, may also affect discrimination experiences and ethnic identity differentially with some individuals of Arab ethnicity self-identifying as being ‘White’ and others self-identifying as being a ‘person of color’ (Awad & Amayreh, 2016).

Many Christian immigrants from the Levant were among some of the earliest immigrants to North America, and several generations later remain a large percentage of the Levantine Arab ethnic group in North America. Many of them have adapted in ways that differ from more recent immigrants who tend to more likely be Muslim (Suleiman, 1999). Thus, these religious differences in Arab Americans and Arab Canadians may be due to generational status and historical immigration pattern differences between families from different religious backgrounds (Amer, 2014).

The extent of the support networks and community organizations may be qualitatively different for Arab Americans who are Christian in comparison to those who are Muslim for more than one reason. Arab Christians are religiously and culturally closer to the dominant western society which may give them more options for active participation in their local communities (e.g., they can attend any of a variety of Christian church services). In addition, they have roots that are more likely to go back several generations in North America with some intermarriages outside of the Arab community. Depending on whether an Arab Muslim family has immigrated to a community with many local resources and relevant activities, they may or may not have as many options available for local community supports.

Although there are some differences among Arab religious groups in North America, Khoury (2017) has noted that additional factors such as socioeconomic status (SES) and income also play a role in acculturation and the associated stresses since many individuals show less strict adherence to their respective religions over time. Thus, similarities may outweigh differences. Similarly, hostilities in the Arab world with Israel may not carry over to everyday interactions between those of the Christian, Muslim and Jewish faiths in North America, as perceived similarities in Middle Eastern culture (e.g., food, traditions) and values may outweigh the perceived differences (Khoury, 2017). The possible lessening of perceived differences among those belonging to various religious groups in North America as a function of SES, income, and acculturation status are issues worthy of future study.

Socialization of Beliefs and Values Within the Family: The Enculturation Process

In developing an Arab heritage ethnic identity, immigrants to North America and their children must be socialized into the beliefs and values of their respective Levantine Arab heritage cultures. Dominant Western values in North America include individualism, in which personal privacy, autonomous functioning, equality under the law, and environmental control by humans are emphasized (Nydell, 2006). In contrast, Arab beliefs and values are more collectivistic with clear distinctions assumed between men and women, an emphasis placed on family and social group goals (rather than personal ones), and a belief in fate or destiny (Nydell, 2006). Individualism includes emotional detachment from the social group, an emphasis on the needs and desires of the self, maximizing personal profits and avoiding personal losses, and the understanding that one’s viewpoint is independent of that of the group (Triandis, 1994). This individualistic approach may be viewed as ‘selfish’ and unhealthy by those who come from collectivistic cultures, where top priority is given to the needs and goals of the extended family (Abi-Hashem, 2008). The collective determines what is appropriate to believe and what the norms are for behaviors that are implemented in a cooperative and self-sacrificing way for the good of the group (Triandis, 1994).

In addition to acculturating to the host culture and adapting to individualistic values, Arab immigrants and refugees become enculturated (i.e., socialized) into some of the collectivistic features of their ancestral heritage culture through interactions with their families around religion, food, music, and other cultural traditions that are specific to their gender (Abraham & Shryock, 2010). Group settings such as religious institutions and family gatherings are where such socialization of beliefs and values often takes place.

In the Levant, there are commonalities in religious values. Islam, Christianity, and Judaism have Abraham of the Old Testament as their common ancestor (Esposito, 2003). According to Nydell (2006), some basic religious values and beliefs are shared among the Christian (e.g., Maronite Catholic, Orthodox) and Muslim (e.g., Shiite, Sunni, Druze) sects, such as the belief in a powerful God, God’s will or fate, religious piety, and conservative, traditional religious practices. In contrast, Western tolerance of youthful rebellion, use of drugs and alcohol, sexual freedoms, unchaperoned dating and other liberal practices associated with individual choice in the West are often considered unacceptable to those of Arab ethnic background because they are thought to weaken family ties and lead to the adoption of immoral social standards. Other religious values and beliefs are different between the two groups. For example, while Christian Arab Americans uphold the separation of church and state as valued in the West, the traditional Islamic view is that religion should be part of the school curriculum and government policies (Nydell, 2006).

Family values oftentimes coincide with the religious values that are enculturated. A sense of community and responsibility toward family members is common among Arab families. The extended family can include several generations who are emotionally close to each other across generations and within the same generation (Nydell, 2006). Family members tend to live in close proximity to one another (Beitin & Aprahamian, 2014; Hakim-Larson, Nassar-McMillan, & Paterson, 2012), and maintain frequent contact, so that children grow up experiencing the traditions as they are handed down from one generation to the next. This is especially the case because grandparents oftentimes live in the same home with their children and grandchildren (Nydell, 2006). Elders are thus highly respected, and obedience and respect to them is emphasized (Hakim-Larson et al., 2012).

In traditional Arab extended families, patriarchal values are upheld. Arab males are expected to provide and care for elders into their old age and parents are more likely to live with their married sons than with their married daughters (Beitin & Aprahamian, 2014). Often, older Arab American adults in need of extra attention and services will live with younger family members instead of seeking care in a nursing home (Hakim-Larson et al., 2012). Social networks that include extended family are often disrupted however during the immigration process. For example, Salma and Salam (2020) examined health and social factors among older adults that included Arab Muslims residing in Canada. Muslim older adults reported that they excluded themselves from social situations that did not seem welcoming, but many of them were able to increase their social connectivity through volunteering, religious programs, employment, community initiatives, and keeping in contact with family in their countries of origin.

Extended family members and elders are intimately involved in the socialization process (Abdulrahim & Ajrouch, 2014). Important for successive generations of Arabs in North America is the process of enculturation in which the children and grandchildren of older immigrants and extended family members learn about the cultural and religious traditions, behaviours, and values that link them to their Arab ancestry (Hakim-Larson & Menna, 2016). Both the younger and older generations may be proactive in the enculturation process in which they engage in a variety of cultural activities (e.g., Arabic language use and music, food preparation, dances) meant to maintain important ties with the family’s culture of origin (Abraham & Shryock, 2010; Hakim-Larson & Menna, 2016; Yoon et al., 2013).

The socialization process for immigrant parents is a challenging one not only because they belong to a different generation, but because they were raised in a completely different culture compared to that of their own children (Abu-Laban & Abu-Laban, 1999a). This process may begin even before the child’s birth and extend throughout early child development into adolescence and emerging adulthood. In the U.S., the limited research on parenting and factors affecting childcare in Arab youth is primarily due to the fact that researchers do not have ethnic identifiers for this population in their reported statistics and large-scale surveys (Dallo, Archer, & Misra, 2014).

Dwairy’s (2010) cross-cultural research on comparing Western and Eastern cultures on parent-adolescent connectedness found that Arab adolescents (e.g., Levantine Bedouins, Jordanians) were more financially dependent and thus connected to their parents than were adolescents from Western countries (e.g., France, Poland) and from India. These findings demonstrate that there were some clear differences in values and expectations in Western cultures that emphasized independence from parents and Eastern collectivistic values where youth were encouraged to maintain connections to their parents. Furthermore, gender by culture interaction revealed that females in Eastern cultures were more financially dependent on their parents and functionally connected to them in their daily activities than were females in Western cultures.

Gender Roles and the Family System

Traditionally, Arab men hold great authority and are viewed as having more power in family matters than women, but they are also expected to protect women and provide for them (Abudabbeh, 2005; Feather, 2004; Glick & Fiske, 2001; Hakim-Larson et al., 2012). Males, especially the eldest male in the household, hold the greatest decision-making power (Hakim-Larson et al., 2012), and boys are given more freedom than girls prior to marriage (Cainkar & Read, 2014). Arab females, in contrast, are traditionally expected to uphold family honor by remaining chaste and modest, demure in their interactions with men, and by staying with their parents until marriage (Shakir, 1997). Brothers are often permitted to exercise authority over their sisters (Haboush, 2005) and often have more social freedom than their sisters. Thus, girls are carefully monitored while boys experience fewer restrictions (Hakim-Larson et al., 2012).

Given the clash of Western values that emphasize individualism and Eastern values that emphasize collectivism, Arab girls and women have had to balance acculturating to the demands of Western independence while enculturating and learning the values of their heritage cultures. Thus, Arab American females have shown great diversity in how they have actually negotiated their ethnic identities with ensuing inner emotional conflict and outright rebellion toward their families and traditions at times (Shakir, 1997).

Arab cultures are patrilineal, and paternalism is valued such that males are afforded greater privileges than females, who are traditionally viewed as dependent upon their families and men; nonetheless, women yield some power in their homes and as mothers (e.g., Beitin & Aprahamian, 2014; Hakim-Larson et al., 2012). Arab families can be thought of as vertically hierarchical with fathers and senior males holding the most power, followed by mothers and other family elders. Obedience is of great importance and thus, speaking negatively about a parent is seen as inappropriate. However, in immigrant families, a role reversal may occur when children act as a translator for their parents (Hakim-Larson et al., 2012).

Some Arab immigrants may adhere strictly to their cultural traditions and try to prevent family assimilation to the host culture, while others may shift to more egalitarian ideals and foster an ethnic identity that values both the heritage and host cultures. In traditional Arab families, family management is seen as the primary responsibility of women, while women’s achievement in education and employment have been of less importance. Among some, however, women’s high educational attainment is seen as a collective benefit for the family. As time spent in the U.S. increases, Arab women have participated in the work force at higher rates (Cainkar & Read, 2014). Traditionally, however, women were expected to marry, and their marriages were arranged by their families with emphasis placed on their financial security, status within the community and continuation of the patrilineal line through having children (Nydell, 2006).

Marriage Customs and Intermarriages

Culturally sanctioned marriages for both Christians and Muslims has traditionally meant marriages arranged by the family and by male elders to a partner who was not only of the same specific Arab ethnic background and religion, but from the same village or clan, and biologically related (i.e., endogamous marriage to cousins; Abudabbeh, 1996). Thus, traditionally there was general disapproval for marriage to non-Arabs and to marriage outside of the family’s religion among Arab Canadians (Hayani, 1999). However, in modern Islamic law, a Muslim man is permitted to marry a non-Muslim woman, but a Muslim woman is not allowed to marry a non-Muslim man (Esposito, 2003). In Hanafi law, the non-Muslim woman must be either Jewish or Christian, which is allowed because of the common Abrahamic ancestry (Abudabbeh, 1996).

However, traditional views on marriage partner selection and family involvement in arranging the marriage are being challenged on several fronts in contemporary Arab families. More young people are delaying marriage and objecting to their parents’ involvement in their choice of partner; these changes coincide with reforms that are being made with respect to women’s roles and rights (Beitin & Aprahamian, 2014), including their education and career achievements.

Educational Expectations, Achievement, and Career Patterns

As both individual and family successes are deeply valued in Arab culture, education and employment are highly regarded (Haboush & Barakat, 2014). Education and job success are a source of family honour, particularly among Arab males (Haboush & Barakat, 2014). It is noteworthy that over 60% of the Arab population in Canada have postsecondary certificates, diplomas or degrees (Mandil, 2019). Similarly, many Arab Americans have obtained a high level of education. Nearly half (49%) of Arab Americans have a bachelor’s degree or higher; comparatively, 32% of those from the overall U.S. population fall into this category (Arab American Institute, 2019a). It must be noted, however, that more recent Arab immigrants may not be as well educated as other Arab Americans (Haboush & Barakat, 2014). Encouraging Arab American parents to become involved in their children’s education, particularly when parenting a child with a disability, has been recommended (Al Khateeb, Al Hadidi, & Khatib, 2015).

Implications for Mental Health

It is important for health-care professionals to consider the individualized mental health needs of their Arab American and Arab Canadian clients while remaining sensitive to their specific ethnic backgrounds. For immigrant families from the Levant, it is especially important to explore and comprehend family members’ pre-migration histories, which may include torture, direct exposure to war atrocities, vicariously experienced exposure to trauma, or dispossession of their homes and property.

The migration experiences to be addressed during the assessment phase of treatment include learning how, when, and where the family members settled even temporarily. Assessment of their post-migration adjustment will need to consider the stresses of adjusting to North American life in a post 9–11 climate of prejudice and discrimination. Key considerations should include the variety of risk factors and protective factors that are potentially linked to the well-being, mental health, and resilience of immigrant families from the Levant, as well as from other regions of the world (Abu-Ras, 2016).

Researchers are now beginning to consider how individual differences in background and perceptions of prejudice and discrimination are linked to psychological outcomes in people with Arab ancestry (e.g., Awad, 2010; Nassar-McMillan et al., 2011). Thus, treatment planning may need to include ways to cope with the broader society’s reactions and cautious skepticism during interpersonal encounters. In addition to learning to cope with the ordinary stresses of acculturation such as adapting to a new home, neighborhood, legal, school, and work system, recent immigrants may have to contend with interpersonal micro-aggressions that involve their ethnic background (Abu-Laban & Abu-Laban, 1999b). For individuals with a war-time history, recovery from collective and cumulative traumas requires specialized assessment and treatments by culturally competent therapists and counselors to build their resilience and provide support for the healing process (Kira et al., 2014).

Mental health therapists, school, career, and family/marriage counselors will all need to enhance their level of multicultural competence with clients of Arab ancestry by increasing their basic knowledge from academic sources (e.g., learning about the culture and research evidence for clinical interventions) and by improving their own personal clinical skills (e.g., overcoming personal biases and developing empathy) (Nassar-McMillan, Nour, & Al-Qimlass, 2016). Although not unique to people from the Arab world, the stigma of attaining mental health treatments through direct help-seeking behavior has been noted by several researchers and providers (Bushra, Khadivi, & Frewat-Nikowitz, 2007), and thus working with clients to overcome this stigma is a worthy treatment goal. Bushra et al. (2007) further note that the history of colonization of the Levantine region has had a negative impact on the self-esteem of the indigenous people who may have an internalized idealization of the West accompanied by an internalized self-denigration; thus, they may reject much of their own native culture, language, and customs. Coming from countries where publicly expressing views on politics and world affairs has historically been censored seems to have led some immigrants to North America to take a stance that involves feelings of fear and distrust of any government agency (e.g., community mental health center); this is especially important when considering the therapist-client relationship given that assurances of confidentiality may be met with skepticism (Bushra et al., 2007).

Another possible treatment barrier that has been noted in the literature on Arab immigrants is the cultural belief in fate which may lead some individuals to believe that there is nothing that can be done to alter their life courses (Hakim-Larson et al., 2007). This view is sometimes reflected in a feeling of resignation that future events are possible only ‘if God wills it’ (insha ‘Allah’ in Arabic). This accepting approach to life is often an adaptive coping strategy and can be viewed as a potential resource in treatment. However, it can potentially be a barrier to those in treatment who may need to more fully explore and actively confront the impact of their background traumas and losses or address the immediate concerns of their life circumstances (Bushra et al., 2007). For example, Thabet and Vostanis (2017) found that PTSD symptoms among Palestinians in the Gaza Strip were predicted by avoidance coping strategies (e.g., wishful thinking and escape-avoidance).

In addition to the challenge of overcoming fatalism when it is not adaptive, clinicians need to be alert to some culturally based beliefs. For example, like those from other Mediterranean cultures, some traditional immigrants from the Levant may hold belief in the power of being given the evil eye. Thus, amulets comprised of artistic depictions of eyes or blue beads are common in Arab culture as a means of protection against evil befalling individuals if they are looked upon with envy (Nydell, 2006). For this reason, Nydell (2006) describes the importance of avoiding the impression of feeling envious. Instead, it is considered appropriate to make statements of goodwill or to offer benedictions or blessings regarding the person’s good fortune or new possession. In addition to beliefs around the evil eye, some traditional Muslims also may hold a belief in the Jinn, sorcery, or black magic (Khalifa, Hardie, Latif, Jamil, & Walker, 2011).

Although there are many barriers to obtaining and receiving appropriate services, one significant factor is that revealing family secrets and any shameful behavior to outsiders is viewed as having a negative effect on the whole family in Arab collectivistic cultures (Abudabbeh, 1996). Less educated Arab immigrants may be especially prone to the effects of stigma and may somaticize their own symptoms of emotional distress or those of their family members; thus primary health care providers may be the ones to initially provide clinical services rather than a mental health professional (Hakim-Larson et al., 2007). Western diagnostic assessment measures may be inappropriate given that Arab immigrants may express their psychological distress as somatic symptoms (Cho, 2018). Cho (2018) recommended the use of culturally valid assessment tools that consider acculturation status, language, how psychopathology is interpreted within the culture, and religious/cultural values relevant to mental health distress. As well, psychologists need to be mindful that Muslims may deny suicidal ideation as it is forbidden in Islam (Cho, 2018). Health care providers thus need to be especially sensitive to the potential need to make appropriate referrals for mental health services.

Preliminary research evidence supports the use of cognitive behavioral therapy (CBT) with adults in the Arab world and the Arab diaspora. In a recent meta-analysis of nine studies with people of Arab ethnic background, Kayrouz et al. (2018) found support for the efficacy of CBT treatment (delivered face-to-face or remotely) for adults with anxiety, depression, and PTSD. Kira and his colleagues (Kira, Ashby, Omidy, & Lewandowski, 2015) have adapted CBT methods specifically to address some of the complexities involved when the traumas experienced have not only occurred in the past but continue to occur in one form or another later on. The model they propose with preliminary evidence for its effectiveness is called the Current, Continuous, and Cumulative Trauma-Focused Cognitive Behavior Therapy (CCC-TF-CBT) . Using a developmental framework that considers the types and frequencies of traumas experienced, Kira et al. (2015) describe the potential utility of eight mechanisms of change when intervening with clients with histories of trauma: (1) safety planning, (2) behavioral skills training such as personal and group-based emotion regulation to address threats, (3) stimulating the will to live and the development of positive dispositional characteristics such as optimism, (4) identity work to enhance the various facets of identity such as personal, social, and role identities as well as collective identity, (5) psychoeducation to help self-awareness and other-awareness, (6) stress inoculation to assist with anticipatory coping, (7) trauma narration to promote processing of emotions by writing about or orally telling the trauma stories, and (8) providing external supports for advocacy, social justice, and reconnection to social groups. There is a clear need for comprehensive services to address the needs of multiply traumatized children, adolescents, and adults with origins from war-torn regions of the world.

Some clinicians who have worked with Arab families have found it helpful to consult with or enlist the aid of the clients’ religious cleric (i.e., an imam or a priest) whenever appropriate (Hakim-Larson et al., 2007). It is important to take the time necessary to work on building a sense of trust in the therapeutic relationship. Providing psychoeducation early in the treatment process and making efforts to destigmatize mental illness can be especially helpful in overcoming potential obstacles to psychotherapy (Bushra et al., 2007). Family dynamics, such as intergenerational conflicts, may be addressed through family therapy (Cho, 2018).

Future Research Directions

Currently, mental health professionals in the Arab region are calling for action to promote research, dissemination of findings, and overall mental health awareness (Maalouf et al., 2019). In conducting research on individuals with origins in the Arab world, a non-pathological approach holds promise with special attention given to variables related to collective values and spirituality (Abi-Hashem, 2006). Although Levantine families face many ongoing stresses and challenges to their adaptation, they also have a rich historical legacy that can foster a sense of realistic pride. A major strength and potential resource of families from the Levant is their culturally sanctioned ability to successfully navigate their extensive familial and community social support networks when such supports are available.

The use of social supports as a means of coping has been identified as a potential protective factor among individuals of Arab ethnicity given the importance of the collectivistic social network (Amer, 2014; Amer & Awad, 2016). Some individuals with Arab ethnicity have a locally available extended family and community social support network that they can turn to for assistance, and some members of this network may provide tangible (e.g., information, finances) and intangible (e.g., emotional support) help, while others in the network may actually add to the ongoing everyday stress and hassles (Hakim-Larson et al., 2007). Other individuals may have suffered great losses within their social support network before arriving in North America and thus they may have increased risks when it comes to mental health issues unless a substitute social support network is formed. These issues are worthy of further exploration in future research studies with Arab Americans and Arab Canadians.

Given the importance and significance of the extended family unit for Arab Americans and Arab Canadians, the influence of both past and current socio-political events on interpersonal relationships is worthy of further exploration. It is especially important to conduct research on preventative interventions for trauma in Arab youth who have experienced war and conflict (Hakim-Larson, Nassar-McMillan, & Ajrouch, 2014).

Conclusion

Families from the Levant are facing a number of challenges to their healthy functioning. While some families have extended across several generations and have been settled in North America for over a century, others have only recently immigrated. A comprehensive biopsychosocial ecological model such as that of Bronfenbrenner’s (1994) has been applied to families under stress (e.g., Swick & Williams, 2006), and can be helpful in examining the socio-political influences on reasons for immigration, and their impact on the problems encountered by families from the Levant in North America. Such challenges include facing prejudicial attitudes and discrimination in a variably hostile post 9–11 sociopolitical climate at the macrolevel, and microaggressions at the more proximal level in everyday interpersonal interactions. Some research evidence suggests that prejudice and discrimination have influenced Arab families and communities regardless of length of time since immigration (Awad & Amayreh, 2016), although more research is needed to better understand how best to promote resilient functioning in spite of the various risks.

Some risk factors are especially important to consider when assessing the mental health of recent immigrants from the Levant. Risk factors include premigration stressors, such as exposure to wartime traumas, disruptions to attaining normal developmental tasks involving adaptive social relationships and school/work achievements, and multiple displacements both within and outside the country of origin. Post-migration stressors involve the stresses of resettlement and acculturation such as learning a new language, attaining gainful employment, learning new cultural traditions and values, and overcoming prejudices and overt discrimination, including bullying. Variations of cognitive behavior therapy have been found to be especially useful in addressing mental health symptoms and ameliorate risks, although more research is needed to test proposed models. While some individuals are more vulnerable to risks than others, others manage to overcome adversities and achieve resilient outcomes and psychological well-being perhaps due to their own psychological resources (e.g., cognitive and emotional skills) or other tangible resources available to them (e.g., social or financial supports).

Thus, even though individuals may have a history of traumatic experiences, current modifiable resources can be fostered in the effort to prevent or address mental health problems. Adaptation to North American life for immigrants from the Levant is thus likely dependent on several factors. These include the extent to which they have adequate and effective resources, supports, and advocacy at various levels personally, socially, academically or at work. Finally, adaptation depends on obtaining resources through the broader socio-political systems and institutions that immigrants from the Levant encounter in their everyday life.