Bonds and barriers: Mental health,service provision,and Middle Eastern/North African cultural identity in the U.S.

Abstract

This exploratory study examined the intersections of Middle Eastern and North African (MENA) American cultural identity and attitudes towards mental health and mental health services. Fifteen in-depth narrative interviews with participants of MENA descent in the United States were analyzed using qualitative thematic content analysis, revealing five primary themes within these data: denial, lack of awareness, stigma/shame, collective identity, and resistance. These results indicate cultural identity plays a unique and significant role in how this population understands and responds to mental health and substance use challenges, in a way that often creates barriers to social service provision and success. Implications and suggestions for how these findings might be used to develop more culturally competent and effective social work interventions for MENA communities are discussed.

Keywords

Mental health substance abuse thematic analysis cultural identity Middle Eastern and North African Southwest Asian North African

Introduction

The existing body of evidence suggests that the health of people of Middle Eastern and North African descent (MENA) may differ from that of other minority racial and ethnic groups in the United States (U.S.), and exposures specific to this ethnic group (e.g., immigration, displacement, acculturation, and discrimination) may be critical indicators of illnesses among this population (El-Sayed and Galea, 2009). Moreover, immigrants and displaced peoples face stressors unique to the experience of migration, that may cause or exacerbate mental health problems, but they access treatment at rates far below the general population (Derr, 2016). Disparities in care put these communities at greater risk of untreated disorders. Crisis-affected populations such as refugees and the forcibly displaced are particularly vulnerable, suffering from an increased rate of PTSD, depression, anxiety and psychosis among refugees (Marquez, 2016; Silove et al., 2017).

Middle Eastern and North Africans are one of the fastest growing immigrant groups in America; while the size of the documented and undocumented immigrant population has tripled since 1970, the number of immigrants from the Middle East has increased more than seven-fold (Camarota, 2002). The region has been existentially defined by displacement and dispossession for centuries, and forced migration has come to be a defining feature today (Chatty et al., 2016; Mechamil et al., 2019). The MENA population in the United States continues to grow rapidly due to political instability and repeated war in the region. For example, since 2010, humanitarian migration from war-torn countries, such as Syria and Yemen, has increased substantially in the United States (Cumoletti and Batalova, 2018). Additionally, recent evidence suggests MENA immigrants in the U.S. self-report high levels of health and mental health struggles (Albqoor et al., 2020) but often remain uniquely resistant to seeking professional support services (Mechammil et al., 2019). Thus, as the numbers of MENA immigrants seeking a new home in the United States continue to grow, it is imperative treatment providers work to respond appropriately to the needs of this expanding population.

There are a variety of terms commonly used to describe the same, or sub-groups of this population: MENA (Middle Eastern North African), SWANA (Southwest Asian North African), Arab, or Middle Eastern. MENA communities are typically lumped together by the general public as “Arab” (Arab and Other Middle Eastern Americans, n.d.). The category encompasses over 20 minorities and ethnicities, including but not limited to Lebanese, Palestinian, Syrian, Egyptian, Armenian, Iranian, Libyan, Moroccan, Kurdish, Afghan, Yemenese, Somali and Iraqi. Despite greater attention to MENA in the media and public discourse in the United States (U.S.), there is troublingly limited research about the health and well-being of this population (El-Sayed and Galea, 2009). The rapidly changing demographics of the U.S. towards an increasingly multicultural society have challenged professionals to provide services to greater numbers of racial and ethnic minority clients (Mindt et al., 2010). However, it has been noted for decades that the relationship between MENA patients and Western health care professionals is often troubled by mutual misunderstanding of culturally influenced values and communication styles (Lipson and Meleis, 1983). The persistence of this problem over time suggests effective treatment necessitates awareness and understanding of unique cultural dynamics. For example, Boghosian (2011) found, cultural identity and family dynamics played a critical role in the therapy experiences of MENA persons, as therapists’ ability to understand cultural identity and family dynamics was related to treatment acceptance and efficacy.

Moreover, MENA in the U.S. increasingly live in a hostile socio-political environment fueled by xenophobia (Soheilian, 2012), recreating and exacerbating negative stereotypes of and discrimination towards this community. This anti-MENA sentiment has risen since, and appears to be directly related to, the election of Donald Trump, as evidence suggests anti-Muslim hate crimes recorded by the FBI are correlated with Trump tweets about Islam (Müller and Schwarz, 2018). MENA individuals were targeted further by an Executive Order enacted January 27, 2017, banning foreign nationals from Muslim-majority countries including Iran, Syria, Iraq, Libya and Yemen, and suspending the entry of Syrian refugees (White House, 2021). And although this policy was revoked by President Biden on January 20, 2021, discrimination towards MENA peoples continues to be a problem in the U.S., as evidenced by recent reports noting a spike in hate crimes during the first 7 months of 2021, ongoing high rates of bullying against Muslim students, and frequent use of Islamophobic hate speech by public officials (Council on American-Islamic Relations, 2021).

Notably, negative public regard and discrimination toward MENA peoples appears to impact Muslims and Christians similarly. According to Hashem and Awad (2021), while most Arab or MENA Americans are Christian, they are often assumed to be Muslim and thus the discrimination towards them is commonly driven by Islamophobia, irrespective of true religious identity (Hashem and Awad, 2021). Such evidence of an ongoing discriminatory environment suggests the U.S. is significantly oppressive towards MENA peoples in a way that negatively impacts the mental health of MENA individuals (Samari et al., 2018; Hashem and Awad, 2021; Tineo et al., 2021), and has implications for culturally competent interventions critically needed within this population (Soheilian, 2012).

The harm caused by discrimination and stigmatization faced by MENAs is further exacerbated by the fact that many people from this region come to the U.S. having been forcibly displaced, and/or experiencing significant trauma due to war, political instability, and violence in their countries of origin. This can be seen in recent waves of immigration from countries such as Yemen and Syria, and from past generations who fled conflagrations such as the Armenian Genocide and the occupation of Palestine (Cumoletti and Batalova, 2018). Indeed, estimates suggest that nearly 40% of refugees arriving in the U.S. between 2013 and 2015 were of MENA nationalities; the majority of whom were forcibly displaced (Mossaad, 2018). The traumas commonly experienced among these peoples can occur in a country of origin, during displacement, or in post-migration environments. And whether categorized as individual (e.g., being the victim of violence) or collective traumas (e.g., being part of a group targeted for persecution or genocide), such experiences are known to result in elevated rates of psychological disorders such as anxiety, and post-traumatic stress disorder (PTSD) (Nickerson et al., 2017).

The significance of these histories cannot be overstated, as research demonstrates such traumas are often passed onto subsequent generations of MENA Americans in the form of intergenerational trauma, in which the traumatic events experienced by one generation, when left unresolved, harm the well-being of those that follow (Awad et al., 2019; Sangalang and Vang, 2017). A growing body of literature examines the role of intergenerational trauma on immigrant/refugee populations; most of which suggests this phenomenon can increase a myriad of psychological risk factors including stress, PTSD, and substance use among younger generations (Daud et al., 2008; Hakim-Larson et al., 2014; Hudson et al., 2016; Philips, 2020). And yet, while these ongoing experiences with trauma suggest a critical need for mental health services within MENA communities, research on this topic also points out that our understanding of how to provide culturally appropriate treatment to diverse populations remains underdeveloped (Jeyasundaram et al., 2020; Cerdeña et al., 2021), particularly with regard to the needs of MENA Americans (Hudson et al., 2016; Soheilian, 2012).

A significant contributing factor to this lack of service capacity is an ongoing limitation within public health research that commonly disallows identification, or analysis of the experiences of MENA Americans. Not only has there not been a single prospective study examining the health needs of this population (Abuelezam et al., 2017), but also research concerned with health inequalities between population groups has been dominated by studies concerned with race-based disparities, instead of ethnicity (El-Sayed and Galea, 2009). This is particularly problematic for understanding the experiences of MENA peoples because there is no MENA racial/ethnic legal identifier included within federal standards for race or ethnicity categories (U.S Department of the Interior, n.d.; Office of Management and Budget, 2016). Instead, the current racial/ethnic classifications aggregate MENA with White, as a person of White descent is defined as “having origins in any of the original peoples of Europe, the Middle East, or North Africa” (U.S. Census Bureau, 2021a). And although a 2015 National Count Test by the Census Bureau added a separate MENA category and overwhelmingly concluded this would result in higher quality data (Jones and Bentley, 2017; U.S Census Bureau, 2021b), the Office of Management and Budget under the Trump administration denied the inclusion of MENA as a new and separate minimum reporting category (U.S. Census, 2021; National Iranian American Council, 2018).

As public health and population data is often gathered according to the federal Office of Management and Budget racial/ethnic categories, MENAs are not regularly identified in national surveys and there is no “checkbox” for MENA origin in most public health studies. Thus, while other legally designated racial/ethnic minority groups in the U.S. such as African Americans or Hispanics are studied in national health disparities research, MENA Americans are not (Agency for Healthcare Research and Quality, 2020). As a result, the unique experiences of MENA communities are rendered nearly invisible within much of the extant scientific literature on public health and substance abuse within the U.S, despite growing recognition that research about these communities remains limited (Abuelezam et al., 2017; Arfken et al., 2009).

The purpose of this study is to directly address this gap in our understanding by examining the relationship between mental health, substance use and cultural identity among persons of MENA descent. To do so, a series of 15 in-depth interviews were conducted to specifically explore the culturally influenced mental health/substance use attitudes and experiences of this population. It is hoped that this research will help expand our understanding of the specific needs of MENA Americans in professional treatment, and provide insight into how social work practitioners can improve their capacity to provide effective services to this population.

Method

This exploratory qualitative study gathered a sample of 15 adults of self-identified MENA descent in the U.S. Data was collected from semi-structured in-person interviews, conducted from January through April of 2019. This study focused on a single primary research question: what is the relationship between MENA cultural identity and perceptions of and attitudes towards mental health and substance use. Thematic analysis (Braun and Clarke, 2006) was utilized to evaluate the data, which revealed patterns and themes regarding the unique challenges and perceptions of mental health and substance use among this population.

Participants

Participants eligible for inclusion were (1) over the age of eighteen (2) interested in and/or willing to discuss mental health or substance health issues and (3) of MENA descent. Requiring self-identification of MENA descent, versus including only self-identified immigrants/refugees, was specifically chosen so this sample could also include the experiences of children of immigrants or refugees; a population known to be shaped by significant cultural expectations of their families, but also intergenerational trauma derived from the experiences of their parents or ancestors (Daud et al., 2008; Sangalang and Vang, 2017). Eligible ethnicities within this population included but were not limited to: Armenian, Iranian, Syrian, Lebanese, Afghan, Egyptian, Iraqi, Turkish, Palestinian, Emirati, Assyrian, Pakistani, Jordanian, and Qatari. Participants were recruited February through April of 2019, through snowball sampling, convenience sampling and social media sites such as Facebook and Instagram. Social media recruitment utilized the researcher’s personal social media network, as well as public social media pages of relevant cultural groups or community-based organizations (details on recruitment strategy in “procedures,” below).

Measures

Researchers used a 23-question interview questionnaire to examine the study’s primary research question (Appendix A). This questionnaire began with five demographic questions about age, gender, ethnicity, religion, and identification as a MENA immigrant/refugee or child of immigrants/refugees. Participants were then asked four dichotomous questions (yes/no) to identify self-reported mental health or substance use issues, and mental health or substance use issues within their families.

Next, 14 primary interview questions focused on participant perspectives and experiences, as they ultimately related to cultural identity and mental health or substance use. To explore these concepts, participants were asked to reflect on family dynamics, community dynamics, and cultural norms related to perceptions of mental health and substance use, and experience with or barriers to treatment. In order to measure mental health, participants were asked to discuss their own conceptualization and understanding of mental health issues and treatment. Mental health may be generally defined as one’s mental and emotional condition. However, conceptualization of mental health can be subjective, vary from individual to individual, and may be impacted by cultural factors. Thus, participants were asked to define what mental health means to them, to describe their individual understanding of mental health struggles, and also discuss how their family/culture perceived these issues. To measure cultural identity, participants were asked to discuss their conceptualization of culture, and how important it is to identity and perspectives within themselves and their community. Additionally, to explore the relationship between both of these variables, participants described how their experiences with, and views of mental health were informed by their unique MENA cultural identity.

Procedure

Participants were recruited electronically, using (1) social media posts on Facebook and Instagram through the researcher’s personal social media networks, and (2) social media posts on Facebook through the public pages of relevant groups or organizations, such as Network of Arab American Professionals and UCLA Armenian Studies Graduate Student Colloquium. All recruitment materials included a brief description of the study, link to an online eligibility survey, and a means of contacting the researchers. Potential participants were provided a link to an initial survey hosted through Qualtrics electronic survey software. Upon clicking this link, potential participants were presented with three questions to determine eligibility. Eligible participants were provided the researcher’s contact information and directed to schedule an in-person interview. Interviews were conducted at public libraries, parks or coffee shops in the Los Angeles area. At the interview, participants were provided informed consent documentation and were asked to consent via signature. All participants were then interviewed, in English. All interviews were completed by one researcher, and the duration of each individual interview was between 15 minutes and 1 hour, with a mean of 36 min. Interviews were audio recorded and compensation in the form of a $20 Amazon gift card was provided to each interview subject. All data gathered through interviews was de-identified immediately following interview completion and subsequently transcribed. All participants were given pseudonyms, and all audio recordings were destroyed immediately after transcription.

Data analysis

Data analysis followed a six-step thematic analysis method developed by Braun and Clarke (2006). This method for analyzing and reporting patterns (themes) across a data set is highly variable in how it organizes and describes data, and interprets aspects of data related to the research topic. Instead of prescribing one specific theoretical grounding, this approach suggests a flexible approach to analysis that challenges researchers to find a match between their methods and the primary research question(s). The flexibility of this approach is why this method was selected for this study. The key to this method is acknowledging that the analysis depends on specific decisions made by the researchers about how themes are determined or understood, such as(i) is an inductive or deductive approach applied; (ii) is the “level” of a theme understood as semantic or latent; (iii) and is a theme’s meaning understood from an essentialist or a constructionist perspective. The current study reflects an assumption that cultural identity likely influences conceptualization of, and experiences with, mental health and substance use issues; and specifically intends to examine if and how MENA cultural identity is unique within this context. Thus, it is important to acknowledge that the following qualitative analysis reflects a deductive, latent, constructivist approach to its application of thematic analysis.

Step one of this analytic process involved one of the researchers becoming familiar with the data by reading and re-reading Microsoft Word-versions of all interview transcripts, while taking copious notes. Step two involved re-reading all interview transcripts, marking what emerged as particularly important or interesting snippets of narrative language in the data using the “highlight” and “comment” functions of Word, and generating an initial list of segments and codes from each interview using an Excel spreadsheet. These codes were then reviewed by both researchers. Step three involved both researchers searching for themes across the data by collating initial codes into categories in a second Excel spreadsheet. For step four, these themes were reviewed, reduced, and refined by both researchers, to ensure that the themes were relevant to the research question and accurately reflect the meanings evident in the data set. Step five then involved defining and naming the final key themes in the data, so as to clearly and succinctly express what is interesting and valuable about the themes. This paper reflects the final step of this analysis process; reporting the results.

Results

Sample

A total of 15 individuals of MENA descent completed the electronic screener, and contacted the researchers to schedule an interview. All 15 completed an interview, and all were between 20 and 35 years old, with a mean age of 29. All participants self-identified as having personal experience with mental health or substance use issues; either regarding themselves or family members. Furthermore, all participants identified as either an immigrant, or the child of immigrants/refugees, and all identified as multilingual, with proficiency in English. Additional demographic information can be found below (Table 1).

Table 1.

Demographic factors.

	MENA Participants (n = 15)
	n	%
Ethnicity^a
Armenian	9	60%
Egyptian	2	13%
Iranian	2	13%
Lebanese	2	13%
Afghan	2	13%
Iraqi	1	7%
Mental health/substance use
Mental health issue	12	80%
Substance use issue	3	20%
Family Substance or MH history	13	87%
Gender Identity
Male	9	60%
Female	6	40%
Religion
Christian	95	20%
Muslim	4	27%
Atheist/Agnostic	3	20%
Other	5	33%

^aSome participants identified with more than 1 ethnicity

Initial coding/theming

Initial coding identified 47 unique codes across 15 interviews that the researchers found interesting. For example, a segment of data coded as “personal responsibility” was, “if you say it’s a drug addiction, they got into it themselves; so, with addiction, it is seen as more their own fault.” An example of data coded as “secrecy” was, “I wouldn’t want to embarrass my family, so I would never tell anyone about [depression] unless they were a doctor and trusted by the family--and it would have to be hush hush.” Subsequent reviewing, collating, and refining ultimately reduced down to 25 final codes, categorized into 5 primary themes deemed particularly relevant to the research question: lack of understanding, shame and stigma, denial, collective identity, and resistance (Table 2).

Table 2.

Emergent themes and codes.

Themes	Lack of understanding	Shame and Stigma	Denial	Collective Identity	Resistance
Codes	limited knowledge personal responsibility weakness limited discourse	social propriety shame/honor isolation/invisibility secrecy acceptance/rejection reputation	undiagnosed conditions generational divide avoidance denial	family honor communal view of mental health communal view of substance abuse family unit resilience familial burden	pride resistance to treatment negative treatment experience insular community strength/vulnerability

Primary themes

Lack of understanding

Lack of understanding is defined as the perception of a general lack of knowledge, awareness, or understanding about mental health and/or substance use issues. This theme was consistent across the data, as all interviews had language categorized within this theme. For example, when asked if she feels supported in regard to mental health/substance use challenges, Samantha (29, Armenian) stated,

“I don’t feel super supported by my community. I think a lot of Armenians don’t understand, they just really lack education on what mental illness, mental health and addiction are. So because they lacked that education, they’re not able to give proper support…I don’t think it’s understood well in the community because it’s never taught in the community or in the family.”

This comment not only highlights a perception that a lack of understanding contributes to limited community support for those who are suffering, but also that the root cause of this is a deficit of education within the MENA cultural community.

Indeed, most participants described how their community’s understanding of mental health or substance use issues was either inaccurate or shallow, with many noting their families viewed addiction as a purely personal choice, and some even mis-attributing mental health issues to superstitious beliefs such as the “evil eye¹” (Berger, 2012). Furthermore, nearly all participants noted this deficit in understanding was exacerbated by a general lack of public discourse. For example, as Amber (27, Iranian) stated, “The fact that there’s no conversation around it is what makes it difficult to understand.” Thus, it appears both limited scientific knowledge, and a hesitancy to discuss the topic are culturally grounded factors that perpetuate a lack of understanding among MENA communities around issues of mental health/substance use.

Shame and stigma

This theme is defined as a perception among participants or their families of mental health/substance issues as fundamentally disgraceful, humiliating, or distressful. Every participant described shame and stigma as significant to mental health/substance experiences, and most connected this phenomenon with particular ways MENA families and communities interpret these challenges. Mike (28, Lebanese) described how this concept can contribute to tension or disagreement between MENA parents and their children, saying,

“There’s a lot of rhetoric about shaming someone for having mental health issues, or seeing them as somehow less-than. If you just go one generation up, you still have a lot of difficulty with young Arabs trying to get their parents to understand why it doesn’t mean you’re not a good son or daughter.”

This suggests perceptions of shame/stigma in this context can contribute to strained intergenerational familial relationships. Interestingly, Mike went on to describe how fear of straining such relationships contributes to hesitance to seek treatment among MENA.

“People are ashamed to acknowledge that they have mental health difficulties and they’re ashamed to go speak to a therapist. And they’re frightened that if they speak to a counselor or a therapist or someone or seek treatment for mental health, that if the word gets out, everyone will think they’re crazy or unstable.”

These dynamics hint at ways in which shame and stigma causes many to try to hide, silence, or disassociate from issues within their family. For example, according to Melissa (29, Afghan),

“The biggest barrier to having conversations about [addiction] is shame, because it’s almost even shameful to have conversations about it. You don’t talk about it…It’s not visible because those people just end up getting disowned. So you don’t get to really see what an Afghan alcoholic looks like because they don’t come out anymore. You don’t get to see what an Afghan heroin addict looks like because they haven’t seen their family in years. Culturally, they tend to think if I pretend it’s not there then it doesn’t exist. That’s the role of stigma and shame, which completely inform that visibility. Because it’s shameful to have that person in your life so you hide them. There’s a stigma to having that person in your life. So you don’t want to discuss what they’re dealing with because you won’t be received well by your community and you’ll actually be scrutinized more for your parental skills.”

Thus, these data reveal the potentially heavy cost of MENAs acknowledging or seeking support for mental health/substance use issues; as the associated shame/stigma may fundamentally jeopardize their perceived or internalized worth, or inclusion in their family or community.

Denial

This theme refers to denial of the existence of mental health or substance use issues by the participant’s family members or cultural community. All participants described experiences regarding this theme. Most examples concerned issues such as depression or anxiety, which were commonly denied by family members. Interestingly, data in this theme often reflected generational issues related to denial; suggesting that older MENAs were less likely to acknowledge the struggles of younger generations they deemed insignificant in comparison to the traumas of their own generation. Anthony (28, Iraqi Armenian) exemplified this phenomenon, stating,

“In my family, mental health issues don’t exist for my sister or me because we’re young. They only believe it to be something that’ll apply to someone like them who was uprooted from their life back in Iraq through the wars. But even then, there is an unwillingness to address mental health issues among themselves.”

Others described how family members denied the existence of their own mental health or substance use issues; specifically, alcoholism, PTSD, and depression. Participants even described their community’s broad denial of the existence of mental health or substance use issues within their entire ethnic community; as if some ethnicities are somehow intrinsically immune to these struggles. In all data within this theme there was a strong presentation of cultural identity or value being tied to a conceptualization of “strength” that disallows acknowledging mental health or substance issues. And for some participants in this study, this prevalence of culturally grounded denial is understood as an intergenerational issue in which unresolved traumas exacerbate and recreate harm experienced by younger generations. As Ana (32, Armenian) stated,

“People totally ignore these things. Addiction, mental illness, they ignore it. They don’t deal with it. It gets passed on, generation to generation. Traumas never get dealt with. So, the same kids experience the same traumas their parents did because they never stop it.”

This suggests there not only exists significant tensions between older and younger generations of MENAs related to these issues, but that younger generations of MENAs are aware this dynamic may contribute to hardships in their lives indicative of intergenerational trauma.

Collective identity

This theme can be defined as a recognition of the prioritization of community identity or family within MENA cultures, and how this influences responses to mental health/substance issues. As Shari (30, Lebanese, Armenian) described, collectivism in MENA cultures commonly takes precedence over the needs of an individual.

“We are really proud…There is always a lot of shame in having any problems…We tend to be very collective. We really emphasize our families. Decisions are made with the family, instead of individually.”

This collectivism often intersected with concepts of familial honor, or reputation in a way that appear to directly influence an individual’s willingness to address their mental health needs. As Alan (35, Afghan) describes,

“[T]he first thing that crosses your mind is how is this going to impact my reputation and what are people going to say about me?...And it’s kind of like tied to your whole family, right? Like you’re dealing with anxiety. Well, how’s that gonna impact the reputation of my entire family across the world included, you know?”

Diana (24, Egyptian) reflects a similar point, saying,

“The role of family is very important in Egyptian culture. I don’t want to embarrass my family, because to them image is important. And it all ties back to them. If something’s wrong with me, it’s a tie back to my family.”

Such comments reveal a recognition among participants that collective identity within MENA cultures can create additional stress or burden for individuals facing mental health challenges, and also suggests individuals may ignore or repress their own mental health struggles as a conscious attempt to avoid family disruption, or to protect cultural values or appearances.

Resistance

This theme is defined as defiance or refusal to accept mental health or substance use issues; particularly with regard to treatment. Many participants described some form of resistance among their family regarding mental health. For example, Melissa (29, Afghan) stated,

“My family is very resistant to treatment. So maybe they have certain diagnoses, but they’re not actually diagnosed because they won’t go. There’s an unwillingness to revisit what has caused their mental health issues. The other thing is there’s just no culturally welcoming safe space for us in treatment.”

Codes categorized within this theme also identified numerous perceived causes of resistance to mental health exploration or treatment within MENA cultures. For example, Johanna (32, Armenian, Iranian) described how concepts of personal responsibility and pride interfere with help-seeking, saying,

“There is a version of a bootstrap mentality: the idea that you should just pick yourself up, this is life and we don’t address it. We just move through it…I think playing into the big cultural resistance is pride. Addressing it means taking a hit to your pride, because you’re told that you’re doing this to yourself.”

Samantha (29, Armenian) noted additional causes of resistance related to gender and concepts of cultural strength, stating,

“They never asked for help, especially men. I think this is because culturally, we have to be the strong, and not show weakness. Any form of vulnerability, even to your family or anybody, is a show of weakness and it’s not to be tolerated.”

It is important to note results of analyses described above revealed significant overlap between codes and themes found in this research, such that a given segment of language identified as important often contained multiple codes, or was categorized within multiple themes. Therefore, primary themes and concepts described above are significantly intertwined in a complex interplay of cultural dynamics. To provide further analysis of these themes, we now turn to a deeper discussion of their meaning and relevance in relation to the research question, and existing literature on MENA culture, mental health and substance use issues.

Discussion

The primary finding of this research is that cultural identity plays a significant and predominantly negative role in how mental health and substance use are both understood and responded to among MENA individuals and their larger communities. Key themes identified in this study suggest this population may have limited understanding of how or why mental health/substance issues manifest, and commonly perceive such challenges as something that is shameful or threatening to their collective identity or familial honor. Furthermore, this research demonstrates the existence of substantial denial of mental health/substance use struggles, and resistance to professional treatment; particularly among older generations of MENAs. In this study, the complex interplay of perceptions and actions related to these issues reveal significant tensions between the needs of individuals or families struggling with mental health or substance use, and a desire to adhere to and reflect cultural values among MENA populations.

This study found a prevalent general misunderstanding of, or lack of knowledge about, Western conceptualizations of mental health or mental health treatment among this population. This lack of understanding manifested in various ways, such as superstitious interpretations of causes of mental health challenges, or the perception of substance struggles as the fault of the individual. Interestingly, participants even described a familial view that mental health and particularly substance use issues are the result of acculturation/Americanization. Regardless of perceived cause, however, the current study clearly and consistently identified that challenges with mental health or substances are almost universally understood as shameful or stigmatized within MENA communities.

In some ways, these findings are reflective of previous research on related topics. For example, studies have shown that lack of knowledge around mental health/substance use is common among MENA peoples, and causes significant stigmatization of these challenges within these communities (Mechammil et al., 2019; Taghva et al., 2017). Research has also identified acculturation as an important factor in this context, arguing acculturative stress can be passed down from American immigrants to their children, and is associated with greater mental health and substance use difficulties among the younger generation (Arfken et al., 2009; Phillips, 2020; Valenzuela, 2014). However, these studies suggested the impacts of such acculturation stress are a form of intergenerational trauma, in which the trauma endured by older generations is passed on to children and manifests as an increased likelihood of mental health or substance use troubles (Sangalang and Vang, 2017). In contrast, participants in the current study suggest mental health/substance struggles are often interpreted by older MENAs or the broader cultural community not as the result of trauma being passed down through generations, but instead as a to-be-expected outcome of the loss of individual strength, cultural cohesion or identity.

This perspective has two fascinating implications in this context of this study. First, it suggests a reason why many older MENAs may lack understanding when responding to mental health/substance use needs in their community, or be particularly resistant to treatment themselves. If blame for these issues is placed on individual “weakness” related to loss of cultural identity rather than intergenerational influencers, then there is no reason to explore the potential ways in which older MENA’s own histories of trauma may impact the lives of their children. And second, the perception that mental health/substance issues are due to loss of cultural identity essentially positions these challenges as anathema to MENA cultural values; and people who struggle with them as not only shameful, but threatening to the future of the cultural community.

Participants in this study suggested that many MENA families respond to this perceived threat by disowning, silencing, or hiding members who struggle with mental illness. This finding is congruent with evidence that MENAs often prefer to keep any mental illness a secret, due in part to fears of harming familial honor (Hudson et al., 2016; Phillips, 2020). Considering this dynamic, it is not surprising that the current study also found individuals or families who struggle with mental health or substance use often respond to this challenge with denial; perhaps as a form of self-preservation when faced with potential familial or community ostracism. However, it appears that denial in this context, given the dominance of collective responsibility over individual needs, can also allow individuals struggling with mental health an opportunity to demonstrate familial deference and cultural respect.

In this study, participants noted the importance of cultural bonds formed through shared histories of genocide, war, displacement, and immigration. Surviving such traumatic pasts often creates an accentuated drive for cultural preservation through maintenance of cultural identity and family unity. And indeed, there is evidence that factors like higher ethnic identity and supportive family structures do increase resilience and reduce the negative impact of trauma within MENA populations (Abu-Raz and Abu-Bader, 2008; Kira et al., 2014; Daud et al., 2008). However, results of the current study suggest that many MENAs believe cultural preservation and familial strength can be achieved, or at least signaled in part, through adherence to cultural norms of silence or secrecy around mental health/substance use issues. This provides some insight into why so many participants in this study describe undiagnosed mental health issues within their families; particularly among older generations. And so, although scholars have identified factors like denial, secrecy, and repression as threats to resilience among MENAs (Hudson et al., 2016), it seems many choose to sublimate their struggles with mental illness/substance use not only to preserve an appearance of familial strength, but also as a means of honoring collective pasts, and re-affirming alignment with MENA cultural values.

Whether fearful of facing familial rejection or actively trying to reflect familial strength, this cultural context can create significant challenges if/when individuals come into contact with Western mental health professionals. Research has shown that stigmatization of mental illness often leads to a dismissal of mental health issues and a lack of awareness of potentially helpful services (Mechammil et al., 2019; Zane et al., 2008). The current study’s findings reinforce this point among MENAs, and further suggest that when faced with countervailing opinions of what causes, or how to deal with mental health struggles that are not aligned with their cultural values, many people in this population respond with resistance towards mental health services. Considering that acknowledging or seeking services for mental illness is traditionally perceived to be an admission of a family’s failure, and familial and cultural pride is so central to MENA cultural identity (Mechammil et al., 2019), it is understandable that this population would be uniquely resistant to receiving or seeking mental health services. And while this resistance appears grounded in a desire to maintain or protect cultural identity, it likely contributes to perpetuating a cycle of avoiding and stigmatizing discourse around mental health within MENAs. Unfortunately, this dynamic likely and ironically precludes cultural healing and resilience development that may be realized through supportive mental health services.

Limitations

Some important limitations existed within this research, and are worth describing. First, the sample size of 15 individuals is a small representation of the large MENA population, particularly in Los Angeles. All of the participants were under the age of 35, which does not account for the views and experiences of older MENA individuals, who may be equally if not more impacted by these issues. Moreover, a large proportion of the participants were Armenian and so other cultural identities within the larger MENA category were not as thoroughly represented. Although the data obtained from these 15 MENA adults provided significant insight into their shared cultural lived experiences, there are many perspectives left unheard, particularly of other ethnicities and age ranges. Future research on this topic could address these issues by more purposefully including a broader array of age groups and ethnicities within a sampled population. Furthermore, future research on this topic could more specifically examine issues related to intergenerational tensions/differences noted in this study, by purposefully gathering a sample of intergenerational MENA, or intergenerational members of the same family. Another limitation of the current study is that it did not allow for specific exploration of, or comparison between MENA participants that have been in the U.S. for a long time, and those more recently arrived. It would be interesting for future research to explore any possible differences in these two experiences, through purposeful comparison of recently arrived MENA immigrants and a sample of MENA peoples who arrived longer ago, or were predominantly raised in the U.S.

Conclusions and practice recommendations

This study identified a number of specific aspects of MENA cultural identity that likely create significant challenges for individuals who struggle with mental health or substance use within these cultural communities. However, these challenges also allow for insight into how practitioners might overcome such barriers to more effectively and respectfully meet the needs of MENA clients. Thus, to conclude this paper, we provide four recommendations derived from the findings of this study for social work clinicians who work with this population.

1. Improve cultural competence to serve MENA clients. Effective service to MENA communities requires clinicians capable of working from a place of cultural humility, understanding and respect. To do so, clinicians who serve such clients could take action to learn about the importance of family responsibility, role of intergenerational trauma and impact of stigma within MENA culture. While the best way to do so is likely to simply meet, listen to, and learn from MENA families, helpful internet-based resources such as The Minority Rights Group Int., or articles such as Abuelezam et al. (2017) can provide a good starting point.

2. Apply methodologies that engage family members. Because family structures play such a unique and pivotal role in MENA communities, clinicians would benefit from actively including family members in mental health/substance use service provision. Utilizing evidence-based, trauma-informed models of treatment, such as Ecosystemic Structural Therapy (Lindblad-Goldberg and Igle, 2017) may be particularly helpful when working with MENA clients. Integrated treatment models such as Structural/Strategic Family Therapy, Multidimensional Family Therapy (MDFT) and Behavioral Family Therapy (BFT) may be effective in the treatment of substance use disorders, in particular (Center for Substance Abuse Treatment, 2004).

3. Collaborate with MENA community groups. Agencies and clinicians serving MENA clients may facilitate access and trust within these populations by engaging faith-based institutions in the community such as MENA mosques or churches. For example, the Center for Faith and Opportunity Initiatives is an initiative to connect faith communities with mental health practitioners. Community collaboration, however, should be equally inclusive of secular MENA community organizations, in order to facilitate the inclusion of MENA individuals who may not identify with faith-based institutions or perspectives. This is particularly important given the decreasing religiosity among younger generations in the U.S. (Kramer and Fahmy, 2020). SWANA-LA and CAIR are two such secular community organizations. Such community outreach would both center the cultural values of MENA communities in treatment efforts, and tap into trusted community members who can work to improve evidence-based understanding of mental health and substance use within the population.

4. Seek training in implicit bias and strengths-based methods. First, MENA-focused implicit bias training is important to reduce biased service provision; particularly because these populations continue to be impacted by xenophobia and discrimination. Second, strengths-based training may allow clinicians to engage with the emphasis on collective cultural identity noted in this study. Many participants described the idea that strength was expected of them because their family and community members survived war, displacement and genocide. Utilizing a strengths-based approach, clinicians may facilitate that cultural emphasis on strength and survival to better serve the client’s therapeutic process. You may consider a strengths-based CBT model, an implicit bias training, or a list of various interventions designed to reduce cultural biases.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

I hereby submit that this manuscript is the original work of the two authors, and does not duplicate any previously published work, including previously published work of the authors. The research reported here has met all ethical guidelines and meets all legal requirements of the United States. As such, the human subjects research reported in this manuscript was evaluated and approved by the Institutional Review Board of California State University at Northridge (IRB-FY19-105). This manuscript has only been submitted to the journal Qualitative Social Work and is not under consideration or peer review elsewhere. This work contains nothing that is abusive, defamatory, libelous, obscene, fraudulent or illegal.

Ethics approval

This study and all activities with human subjects were fully approved according to the expectations of the California State University at Northridge’s Institutional Review Board (IRB-FY19-105). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Consent to participate

All human participants in this research were provided informed consent information, and all participants consented to participate in the study.

ORCID iD

David McCarty-Caplan

Note

Interview Questions

Demographic Questions

1. What is your current age?

2. How would you describe your gender identity?

3. What, if any, religion do you identify with?

4. What ethnicities do you identify with?

5. Do you identify as an immigrant, refugee, or child of an immigrant/refugee?

Mental Health/Substance Use Questions

6. Would you say that you experience mental health struggles, or have you been diagnosed with a mental health condition? (yes/no)

7. Would you say that you experience substance use issues, or have you been diagnosed with a substance use condition? (yes/no)

8. Does anyone in your family have a history of mental health struggles? (yes/no)

9. Does anyone in your family have a history of substance use issues? (yes/no)

Primary Interview Questions

10. In your opinion, what is mental health and mental illness?

11. In your opinion, what is addiction? Do you feel like addiction is a mental health issue?

12. Do you have personal experience with mental health issues or addiction?

13. How are mental health issues viewed in your family and your community?

14. How is addiction/substance use viewed in your family and in your community?

15. Is your cultural identity important to you? What makes up this identity?

16. How do you think your culture’s values and norms impact mental health or substance use issues?

17. How do you think your specific family dynamics impact mental health or substance use issues? Do you feel supported by your family and community in addressing these issues?

18. What are your views of mental health or substance use treatment? Do you or your family members feel comfortable accessing treatment?

19. Have you or your family accessed treatment? How would you describe the experience?

20. What do you think prevents treatment utilization for you and your community?

21. How would you describe your level of trust in professional treatment?

22. Do you feel like treatment professionals understand your cultural values or norms? Is it important for a provider to understand your cultural values or norms?

23. How do you think a shame and stigma impact mental health or substance use issues in your family and community?

References

Abuelezam

El-Sayed

Galea

(2017) Arab American health in a racially charged U.S. American Journal of Preventive Medicine 52(6): 810–812.

Abu-Ras

Abu-Bader

(2008) The impact of the September 11, 2001, attacks on the well-being of Arab Americans in New York City. Journal of Muslim Mental Health 3(2): 217–239.

Agency for Healthcare Research and Quality (2020, December) 2019 National Healthcare Quality and Disparities Report. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr.pdf

Albqoor

Chen

Weiss

, et al. (2020) Self-rated health of Middle Eastern immigrants in the US: a national study. Public Health 180: 64–73.

Arfken

Kubiak

Farrag

(2009) Acculturation and polysubstance abuse in Arab-American treatment clients. Transcultural Psychiatry 46(4): 608–622.

Awad

Kia-Keating

Amer

(2019) A model of cumulative racial–ethnic trauma among Americans of Middle Eastern and North African (MENA) descent. American Psychologist 74(1): 76.

Berger

A.S.

(2012) The evil eye—An ancient superstition. Journal of religion and health 51(4): 1098–1103. doi: https://doi.org/10.1007/s10943-011-9493-5.

Boghosian

(2011) Counseling and Psychotherapy with Clients of Middle Eastern Descent: A Qualitative Inquiry. All Graduate Theses and Dissertations, 898.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

10.

Camarota

(2002, August 1) Immigrants from the Middle East. Available at: https://cis.org/Immigrants-Middle-East

11.

Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Therapy (2004) Treatment improvement protocol (TIP) Series, No. 39. HHS Publication No. (SMA) 15-4219. Rockville, MD: Substance Abuse and Mental Health Services Administration.

12.

Cerdeña

Rivera

Spak

(2021) Intergenerational trauma in Latinxs: a scoping review. Social Science & Medicine 270: 113662.

13.

Chatty

Khater

Culang

(2016) Forced displacement and refugees. International Journal of Middle East Studies 48(02): 439–440.

14.

Council on American-Islamic Relations (CAIR) (2021, July) 2021 Mid-Year Snapshot Summary of Anti-Muslim Bias Incidents. CAIR’s 2021 Mid-Year Snapshot Summary Report of Anti-Muslim Bias Incidents. Retrieved from https://www.cair.com/wp-content/uploads/2021/07/Anti-Bias-Incident-Report-2021_online.pdf.

15.

Cumoletti

Batalova

(2018, January 24) Middle Eastern and North African immigrants in the United States. Available at: https://www.migrationpolicy.org/article/middle-eastern-and-north-african-immigrants-united-states

16.

Daud

Af Klinteberg

Rydelius

(2008) Resilience and vulnerability among refugee children of traumatized and non-traumatized parents. Child and Adolescent Psychiatry and Mental Health 2(1): 1–11.

17.

Derr

(2016) Mental health service use among immigrants in the united states: a systematic review. Psychiatric Services 67(3): 265–274.

18.

El-Sayed

Galea

(2009) The health of Arab-Americans living in the United States: a systematic review of the literature. BMC Public Health 9(1): 272.

19.

Hakim-Larson

Nassar-McMillan

Ajrouch

(2014) Health and well-being in Arab Americans: prevention strategies using a biopsychosocial approach. In: Biopsychosocial Perspectives on Arab Americans. Boston, MA: Springer, 387–401.

20.

Hashem

Awad

(2021) Religious identity, discrimination, and psychological distress among Muslim and Christian Arab americans. Journal of Religion and Health 60(2): 961–973. DOI: 10.1007/s10943-020-01145-x

21.

Hudson

Adams

Lauderdale

(2016) Cultural expressions of intergenerational trauma and mental health nursing implications for US health care delivery following refugee resettlement: an integrative review of the literature. Journal of Transcultural Nursing 27(3): 286–301.

22.

Jeyasundaram

Cao

LYD

Trentham

(2020) Experiences of intergenerational trauma in second-generation refugees: healing through occupation. Canadian Journal of Occupational Therapy 87(5): 412–422.

23.

Jones

Bentley

(2017, February 28) Overview of 2015 National Content Test Analysis Report on Race & Ethnicity. census.gov. Retrieved from https://www.census.gov/content/dam/Census/newsroom/press-kits/2017/2015nct_presentation_jones.pdf

24.

Kira

Amer

Wrobel

(2014) Arab refugees: trauma, resilience, and recovery. In: Biopsychosocial Perspectives on Arab Americans. Boston, MA: Springer, 175–195.

25.

Kramer

Fahmy

(2020, May 31) Younger people are less religious than older ones in many countries. Available at: https://www.pewresearch.org/fact-tank/2018/06/13/younger-people-are-less-religious-than-older-ones-in-many-countries-especially-in-the-u-s-and-europe/

26.

Lindblad-Goldberg

Igle

(2017) Ecosystemic structural family therapy. In: Lebow

Chambers

Breunlin

(eds) Encyclopedia of Couple and Family Therapy Cham: Springer.

27.

Lipson

Meleis

(1983) Issues in health care of Middle Eastern patients. Available at: http://repository.upenn.edu/nrs/1.

28.

Marquez

(2016, December 8) Mental health among displaced people and refugees: making the case for action at the World Bank Group. Available at: http://pubdocs.worldbank.org/en/728101481211075256/Mental-health-among-displaced-people-and-refugees-pmarquez-version-december-8-2016.pdf

29.

Mechammil

Boghosian

Cruz

(2019) Mental health attitudes among Middle Eastern/North African individuals in the United States. Mental Health, Religion & Culture 22(7): 724–737.

30.

Mindt

Byrd

Saez

, et al. (2010) Increasing culturally competent neuropsychological services for ethnic minority populations: a call to action. The Clinical Neuropsychologist 24(3): 429–453.

31.

MOSSAAD

(2018) Annual flow report: Refugees and Asylees: 2015.2016. USCIS Office of Immigration Statistics. Policy Directorate. Retrieved January 17th, 2022 https://www.dhs.gov/sites/default/files/publications/Refugees_Asylees_2015.pdf

32.

Müller

Schwarz

(2018) Making America hate again? Twitter and hate crime under Trump. Unpublished working paper. University of Warwick.

33.

National Iranian American Council (2018, February 6) Mena category rejected by census Bureau despite clear benefits. NIAC Action. Retrieved from https://www.niacouncil.org/news/mena-category-rejected-census-bureau-despite-clear-benefits-2/?locale=en

34.

Nickerson

Liddell

Asnaani

, et al. (2017) Trauma and mental health in forcibly displaced populations an International Society for Traumatic Stress Studies Briefing Paper. An International Society for Traumatic Stress Studies Briefing Paper, 1–37.

35.

Office of Management and Budget (2016, September 30) Federal register: standards for maintaining, collecting, and presenting federal data on race and ethnicity. Federal Register: The Daily Journal of the United States Government. Retrieved January 26, 2022, from https://www.federalregister.gov/documents/2016/09/30/2016-23672/standards-for-maintaining-collecting-and-presenting-federal-data-on-race-and-ethnicity

36.

Phillips

(2020) Moving on/moving with: healing transgenerational trauma through dance/movement therapy with Iraqi-American Jews.

37.

Samari

Alcalá

Sharif

(2018) Islamophobia, health, and public health: a systematic literature review. American Journal of Public Health 108(6): e1–e9.

38.

Sangalang

Vang

(2017) Intergenerational trauma in refugee families: a systematic review. Journal of Immigrant and Minority Health 19(3): 745–754.

39.

Silove

Ventevogel

Rees

(2017) The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry 16(2): 130–139.

40.

Soheilian

(2012) Competent counseling for middle Eastern American clients: implications for trainees. Theses and Dissertations. Paper 1151.

41.

Taghva

Farsi

Javanmard

, et al. (2017) Strategies to reduce the stigma toward people with mental disorders in Iran: stakeholders’ perspectives. BMC Psychiatry 17(1): 1–12.

42.

Tineo

Lowe

Reyes-Portillo

, et al. (2021) Impact of perceived discrimination on depression and anxiety among Muslim college students: The role of Acculturative Stress, religious support, and Muslim identity. American Journal of Orthopsychiatry 91(4): 454–463. DOI: 10.1037/ort0000545

43.

U.S. Census Bureau (2021a, December 3) About the topic of race. Census.gov. Retrieved from https://www.census.gov/topics/population/race/about.html

44.

U.S. Census Bureau (2021b, October 18) Research to improve data on race and ethnicity. Census.gov. Retrieved from https://www.census.gov/about/our-research/race-ethnicity.html

45.

U.S. Department of the Interior (n.d.) Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. Office of Civil Rights. Retrieved from https://www.doi.gov/pmb/eeo/Data-Standards

46.

Valenzuela

MPd

(2014) Dancing with mothers: a school-based dance/movement therapy group for Hispanic immigrant mothers. American Journal of Dance Therapy 36(1): 92–112.

47.

White House (2021) Proclamation on ending discriminatory bans on entry to the United States. Executive Order: 13780.

48.

Zane

Morton

Chu

, et al. (2008) Counseling and psychotherapy with Asian American Clients. Reading in multicultural practice, 241–264.