In Iranian culture, both guest and host abide by the rules of taroof.
Under this cultural creed, guests act as if they have no needs while their hosts try to figure out what their needs are. It's a sort of unspoken test of wills.
So when Orange County mental health workers began seeing a rise in Iranian clients, taroof occasionally became a point of contention. Clients or their families would offer tea. If it was declined, coffee was served. Soon, the table was set with food. There might even be a gift. But county workers were curious about their hosts' motivation.
"One of the questions is, 'If an Iranian brings me food or flowers . . . are they bribing me?' " said Faye Hezar, who was hired by the county last year to conduct a series of training workshops to teach workers about Iranian customs and traditions. "They are not really trying to buy your favor; it is just culture."
Recently, the number of Iranians in the county who speak Farsi as their primary language and are Medi-Cal eligible surpassed 3,000. State law requires that once an ethnic group passes this numeric threshold, counties must conduct staff training exercises on culture and language.
The law is meant to improve access to mental health services for immigrants and those with limited English skills, officials said.
In her workshops, Hezar explains such concepts as taroof and addresses how discussion of mental health issues remains taboo in the Iranian community. Those who attend her classes are mostly mental health workers but also include probation officers and psychologists in private practice.
Hezar, who has a background in psychology, also talks about the different waves of Iranian immigration and what has contributed to the rise in the county's Farsi-speaking clients.
She and others said the increase in Iranian clients that the county is seeing is largely attributed to two sub-groups: the aging immigrants who came here during the Islamic Revolution 30 years ago and the more recent immigrants who tend to be political asylum seekers who often have fewer financial resources.
"Twenty years ago they used to come really rich, but now the people we see are regular or low-income," said Nahla Kayali, executive director and founder of Access California Services, which serves the Arab and Muslim populations in Los Angeles and Orange counties.
In the last two years, the number of Iranians walking through the doors of Access' Anaheim office has grown to 10% of their clients. In response, Kathy Rostamzadeh was hired as an Iranian case manager, and there are plans to hire another soon.
There is a noticeable difference in financial means between the older and newer immigrants, Rostamzadeh said. "The newcomers, they basically take their suitcase and come here with open hand," she said.
Rostamzadeh is working on translating into Farsi the county's Family-to-Family Education program handbook, which teaches families about mental illness and how to support loved ones. The handbook is about 4 inches thick.
Clayton Chau, associate medical director for the county's Behavioral Health Services, said that in order for county staff to provide effective healthcare education in the Iranian community, it is necessary to have an understanding of their culture. "We try to make sure that our staff is culturally competent in a way that they can respond appropriately to the consumer and understand why a certain ethnic group responds a certain way," said Chau, who has personally treated about a dozen Iranian patients.
One case involved an Iranian man who had attempted suicide. He had been a successful businessman in his homeland but was ashamed when he came to the U.S. because he suffered from mental illness. He was referred to the Orange County Mental Health Department.
"Prior to the training, I didn't understand the significance of the role of a male figure in the Iranian culture," Chau said. "Even with mental illness, many men are expected to be the decision makers in their immediate family. This has added stress to the consumer when he is in crisis."