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In a study of the Arab culture it was noted that Arab parents tended to present all their complaints as somatization problems, with conversion symptoms being common. It was also noted that the authoritarian nature of their society led the patients to expect psychotherapy to be an experience in which an expert authority would solve problems for them, advise them or control the situation. The idea of the patients helping and participating in solving their own problems with the assistance of a therapist was incomprehensible (Gorkin, et al. 1985) (Ozbek, Volkan, 1976,197 1) (Prothro, 1961).

Turkey is a Moslem country. Though it is non-Arab, the Turks have been intimately involved with the Arabs for centuries. The predecessor of Turkey was the Ottoman Empire that ruled and controlled the Arab lands for centuries. The cultures were intertwined. Historically and into the present the Turks have been more Westernized and more socially and industrially advanced than their Arab co-religionists. Therefore, if we examine some psychosocial element in Turkey we may get some insight into that aspect of the Turkish culture, and likely the Arab culture as well.

Related to the preceding is an interesting series of studies (Gorkin, et al. 1985) (Ozbek, Volkan, 1976, 1971) (Prothro, 1961). In summary it was found that traditional society (the closest to Muslim fundamentalism) had the highest frequency of organic brain problems and mental retardation. An adult villager in rural Turkey generally believed that various illnesses were the result of being possessed by a "Jinn." This could occur for failure to take a ritual bath after "sexual activity," whether the activity was heterosexual, masturbatory, or only in a dream. It was believed that what might result would be a "stroke," aphasia, sexual impotence, delusions and hallucinations. When the same villagers were presented with fictitious case histories of schizophrenia, alcoholism, paranoid psychosis or a severe anxiety reaction, only 10% thought they were mental disorders. The rest of them believed that they were in the realm of normal or only some minor trouble. When the same questions were asked of the urban area more educated Turkish males, only 15% could recognize them as being mental problems. They also thought that sexual impotency was the result of magic or being possessed by Jinn.

Though alcohol is forbidden in the Moslem world, there is increasing alcohol abuse and drug abuse, especially hashish and codeine with increased use of over-the-counter tranquilizers bought with or without a physician's prescription (EI-Sayed, et al. 1986) (Gadallah, 1962) (Girgis, 1961) (Gorkin, et al. 1985) (Ozturk, 1973) (Pakrasi, 1970).15

Gorkin (1985) and others have seen some of the more common symptoms presented at various psychiatric clinics and they are as follows: 1) Intolerance of mental problems presenting primarily as somatic complaints (Racy, 1980). 2) Conversion symptoms such as paralyses are not uncommon. 3) Paranoid-like fear about confidentiality. 4) Sexual seductiveness and sexual punitive behavior occurring in the same family toward the same individual. 5) Males fears of castration and impotence. 6) Women's fears of sexual temptation. 7) Homosexuality commonly found (in Iraq it is called Al-Issal and in Kuwait it is called Parhad), with a fear especially of rape by an older and stronger male. 8) Explosive outbursts of temper. 9) The world is seen in either-or, and black or white terms. 10) Difficulty in tolerating frustration. 11) Difficulty in dealing with a relationship therapy in any form of psychotherapy.

In statistical studies and clinical observations at me&cal clinics (Al-Khani, 1986) throughout the Arab world the following elements were repeatedly found: 1) High rate of infanticide particularly females. 2) High rate of psychosomatic difficulties. 3) Abusive-to-sadistic responses to children and women. 4) Denial of psychotic symptoms as due to mental illness. 5) Many physical "accidental" injuries to small children.

Discussion

In the Arab Moslem world life is not a world of reality as we understand it in the West. The world in the Arab experience consists of what the child perceives and understands of that world at various periods of its early development just as a child does in our society. This material is retained in the unconscious. It is part and parcel of the brain in not only psychological, but also in chemical and anatomical development.

We can make many guesses about what the ego development will be of children exposed to these inappropriate deprivations and stimulation's. What has been described in this paper is by far not rare, it is much more common than the world wants to know about or the Arabs would like to admit publicly. The pathology occurs early, is extensive and takes place in the first three years of life.

We can pose many questions to ourselves and come to various answers which would be similar in quality. Namely, what would one expect the woman to feel about herself if at her earliest experience in life, her mother is depressed and/or negative towards her? What would a child's developmental perception be if disease and general disability is a result of malnutrition, etc. in the first two years of its life? If the same child is depreciated, denigrated and passed from one caretaker to another, what might its reactions be? What might a little girl's reactions be if she experiences the depreciation and denigration of females and sees a contrasting relationship to the males in her environment? What would her perception of reality be if magical thinking, denial and projection are the adult modes of functioning in reality? What would her reactions be if her genitals are attacked emotionally, morally and then physically as well? What might her reactions be to sexuality in general and to the product of her sexuality, her children, and the relationship to her husband be if sex is seen as an attack by her husband? What might her reaction be to herself, to children, to child-bearing, to the world if her genitals are so traumatized not only in her childhood but as a result of the various genital complications due to related diseases and injuries? How can she be expected to respond to her children? What happens to all her turmoil, rage, confusion, conflict?

One could ask similar questions about the male. What might a little boy's reaction be if he is raised in such an environment, with such an experience about women, and such an experience about his own genitals? What might this little boy's feelings be if his genitals are repeatedly fondled and touched and then they are attacked later in a circumcision? What might this little boy's reaction be to being a male as well as his response to a female if he is terrified of his father and at the same time threatened by the seductiveness of his mother? What might his response be to his mother, to women in general with this kind of confusion and lack of protection from injury if women are also depreciated? How will he respond to his children?

Fritz Redl used to refer to the "cassette conscience" of the teenager. Teens would replace their "cassette" with the teen peer group cassette when they were with that group. In a similar fashion Arabs tend to not have their own conscience as much as an external one, i.e. the "cassette conscience" of their part of the Arab world.

In a similar descriptive vein it can be observed that when an Arab couple marries each will bring to the marriage all the results of these previously described external experiences, particularly a sense of body mutilation and a hurt (fragile) sense of self. It is likely that the wife will become the repository of her husband's projections of hurt self image and poor control of aggressive sexual impulses.

The long swaddling period prevents activity and inhibits the developing sense of autonomy and cognitive and emotional growth. Further, with the impaired self and object representations there is a resultant impairment in judgement, anticipation, frustration tolerance, and impulse control.

Their children, especially the girls, will receive less nurturing protection. The boys will have identification with the aggressor as part of their masculine identities. The little girls will see themselves as less human by identifying with a depreciated less human (less male) mother.

There are many qualities about the Arab character which are reminiscent of psychological features of the anal, preoedipal, period (I to 3 years of age). The need to perform for another's approval, particularly authority figures, is a prominent feature. On an individual level, when a person whose actions are determined by external controls (promises of reward or punishment) can manage to break away from that control he might act out how he has been feeling internally all along. The taking away of restraints can result in swings of emotion with temper outbursts. There is a 'black or white' quality to this type of personality organization. Typically the adult anal character is his own worst enemy, with a punitive harsh and corrupt anal conscience. The effect on a society in which vast numbers of individuals collectively experience life and function in this manner is significant.

There are certain characteristics in the Arab world that are similar to clinical pathology with which we are familiar; namely: 1) The masochistic character - who has depressive moods, a tendency to complain of being a victim of fate or of malevolent outsiders. Sadistic characterology may episodically predominate. 2) The narcissistic character needs to be admired by others and to be entitled to more than he is getting. This type also tends to fluctuate from elation to depression or a narcissistic rage when self-esteem is injured. This character type also lacks an ability to really care for others.

How psychologically healthy are the Arab children? A partial psychological profile could help answer that question.

By and large, there is little achievement of the phallic-oedipal phase. Fixation is at the pregenital level. Libidinal phase development is at an oral-anal level. The marked depression tendency points to a turning against the self, i.e. a negative cathexis of the self. The cathexis of objects is poor (e.g. wives and children). Aggression seems to be clearly at the oral-anal level.

The ego apparatus seems to show defects, with clear evidence of arrested ego development. This can be seen in the types of defenses that are used i.e. denial and projective identification. These defenses seem to interfere with ego functioning, e.g. time relationships, magical thinking, and abuse of women and children. Their behavior (not just thinking) shows a distinct inhibition of ego functioning, due to an arrest of ego development. Dynamically they try and externalize their conflicts. Their fear of authority in childhood becomes translated into an "anal conscience" not a true superego. Further, there is such a fear (hatred) of women that it indicates a conflict about their own gender identification/sexual role.

There is little insight in this group, because that requires good reality testing. Their magical thinking, animism, time distortion, etc. play such a large role that reality testing is impaired. Another limitation on insight is the tendency to avoid self observation (critical evaluation) due to the fear of shame. The fatalism ("It is Allah's will") produces little motivation to change or to critically evaluate their circumstances. The self absorption without critical self evaluation indicates the psychological immaturity of this population.

One can ponder the psychological significance and resultant problems when there is such a predominance of aggressive drive elements at all stages of ego development, and in all their significant relationships, at the expense of the libidinal part of life. Further, we wonder about the significance of the limitation of drive fusion as well as neutralization of libidinal and aggressive energies.

If a child has a solid base in the first three years of life and the security of a family in which there is love communicated between parents as well as to the child and no significant abandonment, rejection, threats, or injury he will as an adult in a relatively stable way be able to cope with the complexities of human relationships with some measure of success. Even if there is difficulty in that period of time, the most serious problem will be a neurosis without significant somatization. If, however, in establishing one's body image, body ego, sexual identity and gender role (tasks of the first three years of life) there is significant trauma, then the child will develop a borderline ego organization, serious psychosomatic pathology, or various degrees of psychosis.

"When all is said and done, the most important person in our universe is the mother who can pass along her love, nurturing, security, and stability to her daughters, who will continue the cycle and pass along these characteristics to her children. The preparation for motherhood begins in infancy. Without this foundation in the first two to three years life, the little girl will become impaired in her functioning as a mother. This means that the most important person in the world is a newborn female child. What a horrible tragedy that she has been the object, throughout history, of society's prejudice and abuse. Without that love from mother we flounder; without it, there is pain, violence, death - even war. The only hope our civilization has ties in changing our response toward women. They should not be treated as equal to men; they deserve better" (Breiner, 1990).

Wordsworth said, "the child is father of the man." The future of the Arab nations and how they coexist with the family of nations depends on how they treat and perceive their children. This brief report is offered as food for thought as the Arab and non-Arabic world struggles with what must be done to improve the lives of all their children.

Summary

There is a general quality of an "Arab personality" and a special "Arab-world". Some of the characteristics are: 1. words substitute for behavior, leading to confusion of words being equal to action, 2. all Arabs are brothers, yet 3. there is ubiquitous hostility between groups, 4. the non-Arab world is the enemy, 5. tribal and patriarchal attitudes are pervasive, 6. difficulty in admitting mistakes, 7. fatalism, 8. emotionally expressive and labile, 9. father is dictatorial and mother (women in general) is submissive, females are denigrated, 10. marked corporal punishment, 11. language and behavior has a time, verb tense distortion, 12. magical thinking, 13. either/or, right/wrong, black/white attitudes, 14. exaggeration is expected, 15. a special code of honor and courage different from the West, with vendettas and murder considered reasonable and required for non-threatening behavior to them, 16. extensive sexual stimulation and prohibition, 17. genitals of children stimulated and attacked, with more extensive abuse to female genitals (mutilation), and 18. extensive physical and psychological problems in giving birth and caring for the young child. There are age inappropriate stimulations and deprivations, general encouragement of hostility, and pervasive denigration and abuse of females of all ages, with resultant pathology that can be seen in medical and psychological clinics, social settings, political structures, and individual evaluations.

1Ibn Kaldun (1321-1406A.D.) noted the savagery of the Arab population in his famous "Introduction to History (Mugaddima)."

2Ahmd al-Maqrizi (1364-1442 A.D.) a Mameluke historian and Egyptian.

3"Dam Butlev Dam"

4In the industrialized countries maternal death rates are now rare events. Average lifetime risks for women dying of pregnancy related causes is
between I in 4 thousand and I in 10 thousand. In contrast for women in developing countries such as the Arab world, the risk is between I in
15 and I in 50. ("Safe Motherhood", Newsletter of Worldwide Activity and Maternal Health, issue 1, Feb. 1990. p. 5)

5When treatment is even-handed, girls should be at less risk of dying in the first years of life than boys. The odds are 1.15:1 in favor of girls.
the biologic advantage of girls has been canceled out by their social disadvantage." Toddler age Sweden 1.27, Egypt .071, Jordan 0.81.
World Health Organization, "Preventing Maternal Death", p. 66, 1989.

6Maternal Mortality Rates", 2nd Edition, World Health Organization, Div. of Family Health, Geneva, 1986.

7Prevention of Maternal Mortality", Report of a WHO Interregional Meeting, Geneva, Nov. 11-15, 1985.

8"Safe Motherhood", The Prevention & Treatment of Obstetric Fistulae, WHO, Report of a Technical Working Group, Geneva, Apr. 17-21,
1989.

9"Maternal Health & Safe Motherhood Program, Obstetric Fistulae, WHO, Geneva, 1989.

10"A recent conference at Addis Ababa organized by the Inter Africa Committee (IAQ on harmful traditional practices has decided that instead
of using the old term of circumcision that the new term be "female genital mutilation."

11"Health Implications of Sex Discrimination in Childhood": A review paper and an annotated bibliography. WHO/UNICEF/FHE, Geneva, 1986.

12"Women with the obstetric fistula leaking urine and feces have such difficulty that often their husbands will abandon them. This forces them
to run away from their village and even commit suicide. This information has been extensively reported by Dr. Hassan Abbo as well as Dr.
John Kelly of the World Health Organization and Dr. Farhang Tahzib ("Safe Motherhood", Feb. 1990, p. 4).

13The paternal grandmother will sing "Why did you come, 0 girl, when we wished for a boy? Take the Zala (Jar) and fill it from the sea, may you
fall into it and drown" ("Sex Differences in Child Survival and Development," Evaluation Series, No. 6, 1990) UNICEF: Regional Office For
The Middle East & North Africa, p. 7.

14"Yossi Goell, "Islam and the Israeli Arab" The Jerusalem Post International Edition, P. 8B, 10/5/91.

15"Some of the preceding material is excerpted from the report presented to the Michigan Psychiatric Society by A.Salarna, M.D., July 1991.

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Dr Bremer is Associate Professor, Psychiatry at Michigan State University, and Assistant Professor Psychiatry at Wayne State University. His address is 31811 Middlebelt Road, Suite 203, Farmington Hills, MI 48334-2368.



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