Mental Health Attitudes Among Middle Eastern/North African Individuals In The United States Choose one approach from the following: Basic qualitative inqu

  

Choose one approach from the following:

Basic qualitative inquiry

Qualitative case study

Grounded theory and realism

Phenomenology and heuristic inquiry

Mental health attitudes among Middle Eastern/North African
individuals in the United States
Molly Mechammil, Sara Boghosian and Rick A. Cruz

Emma Eccles Jones College of Education and Human Services, Utah State University, Logan, UT, USA

ABSTRACT
Middle Eastern/North African (MENA) individuals may have
heightened risk for developing mental health problems due to
unique cultural stressors. However, traditional cultural and
religious practices and beliefs socialised within the family
environment may reduce the likelihood of seeking mental health
services. This qualitative study aimed to better understand the
intersection of cultural, religious, and mental health attitudes
among MENA individuals. Semi-structured telephone interviews
were conducted with MENA adults who had received therapy
services (N = 13) and were analysed for emergent themes.
Respondents reported lack of understanding of mental illness
within their communities, and prominent levels of perceived and
self-stigma. Families and religious practices/beliefs played an
important role in responding to mental illness. Results suggest
that incorporating psychoeducation and community awareness
campaigns alongside religious services may help to reduce
barriers to receiving mental health treatment.

ARTICLE HISTORY
Received 24 February 2019
Accepted 10 July 2019

KEYWORDS
Middle Eastern; MENA;
stigma; mental health
attitudes

Negative attitudes regarding mental health serve as a notable barrier to seeking mental
health services and are particularly prevalent in racial/ethnic minority groups (Seeman,
Tang, Brown, & Ing, 2016). However, little is known regarding the mental health attitudes
among individuals of Middle Eastern/North African (MENA) descent (Al-Krenawi & Graham,
2016). This is a notable shortcoming as these individuals are a growing demographic sub-
group in the United States (Krogstad, 2014) and are at an increased risk for experiencing
mental health problems (Padela & Heisler, 2010). The purpose of this study was to inves-
tigate the intersection of cultural attitudes, religious and faith perspectives, and mental
health attitudes among individuals of MENA descent living in the USA. This information
will help to better understand cultural barriers to service utilisation and will provide
insight into ways to tailor treatment to be culturally appropriate for individuals of MENA
descent in the USA.

MENA region and population

People of MENA heritage are currently classified as White by the Census, therefore, it is
extremely difficult to accurately estimate the number of individuals currently living in

© 2019 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Molly Mechammil mechammil@aggiemail.usu.edu

MENTAL HEALTH, RELIGION & CULTURE
2019, VOL. 22, NO. 7, 724–737
https://doi.org/10.1080/13674676.2019.1644302

the USA. Although Arab Americans constitute only a portion of MENAs, current estimates
indicate that there are over three million Arab Americans living in the USA and they are
one of the fastest growing minority groups (Krogstad, 2014). There is tremendous hetero-
geneity and complexity to the ethnic, national, and religious identities for people of MENA
descent. For the purposes of this study, a person of MENA heritage is defined as a person
of any ethnic or religious group who comes from this defined geographical region:
Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman,
Saudi Arabia, Sudan, Syria, Tunisia, Turkey, United Arab Emirates, Qatar, and Yemen.
People from the MENA region have various ethnic identities, such as Arab, Kurdish,
Persian, Assyrian, Iranian, Palestinian, Armenian, or Jewish. Individuals may also identify
more with their nationality (e.g., Iraqi rather than Arab or Kurdish), or choose to use
both ethnic and national labels. While a majority of individuals from MENA countries ident-
ify as Muslim, many identify with other religions, such as Christianity or Judaism (Erickson
& Al-Timimi, 2001). There is also great heterogeneity within groups of individuals with
similar identities, due to in part to differing acculturation levels. Acculturation processes
involve adapting to US culture while also maintaining elements of heritage culture
(Schwartz et al., 2015), a process that has been described as “living in two worlds”
(Schwartz et al., 2015, p. 18). We focus on this group due to their growing population in
the USA, lack of representation in psychological research, and increased risk for experien-
cing mental health concerns.

Mental health risk and attitudes

MENAs are at increased risk for experiencing mental health problems (Al-Krenawi &
Graham, 2016). Similar to other minority groups, MENAs in the USA often face stressors
related to emigration and adapting to the US society, which are associated with higher
levels of psychological distress, feelings of insecurity, poorer levels of overall health, and
lower levels of happiness (Padela & Heisler, 2010). In particular, MENAs have been con-
fronted with increasing experiences of hate crimes, discrimination, and marginalisation fol-
lowing the events of 9/11 (Ibish, 2003), which has remained consistently high since then
(Nassar-McMillan, Lambert, & Hakim-Larson, 2011). However, mental health attitudes,
shaped by cultural beliefs and values, may represent a barrier to using formal services.

Mental health attitudes are defined as perceived cultural beliefs and personally held
beliefs about mental health, stigma associated with symptoms and treatment of mental
health, and common responses to mental illness. Within MENA populations, stigma has
been identified as the greatest barrier to individuals utilising formal mental health services
when needed, in particular the view that seeking services is shameful (Aloud & Rathur,
2009). Religion may also contribute to high levels of stigma among MENAs, as emotional
problems are often viewed as a weakness of faith (Soheilian & Inman, 2009). There are two
different forms of stigma that may correspond with one’s perception of mental health,
including public stigma (the stigma that individuals feel from others around them regard-
ing mental health) and self-stigma (how the person feels about their own mental health
problems; Vogel et al., 2017). There is robust evidence suggesting that perceived stigma
contributes to self-stigma among individuals, which then negatively influences their atti-
tudes towards seeking treatment for mental health problems (Topkaya, Vogel, & Brenner,
2015; Vogel et al., 2017). However, a large majority of the research on MENA mental health

MENTAL HEALTH, RELIGION & CULTURE 725

attitudes and stigma has focused on individuals living in their home countries (Eapen &
Ghubash, 2004; Gearing, Brewer, Schwalbe, MacKenzie, & Ibrahim, 2013) or a very
specific subset of individuals living in the USA (e.g., only Arab Muslims; Aloud & Rathur,
2009; Khan, 2006). Therefore, it is important to broadly describe the different features of
mental health stigma that exist among the diverse US MENA population.

Sources of support for mental health

To our knowledge, there is no empirical research on the rate of mental health service util-
isation for MENAs in the USA. However, research has identified a number of factors that
interfere with MENAs’ access to services, including: concerns regarding confidentiality
and multicultural competence of professionals, causal beliefs of mental illness, threats
to family honour, and perceived shame/stigma in seeking services (Al-Krenawi &
Graham, 2016; Aloud & Rathur, 2009). It is highly likely that MENAs underutilise formal
mental healthcare due in part to these negative mental health attitudes (Al-Krenawi &
Graham, 2016). Traditionally, seeking help for mental health problems is seen as a weak-
ness among MENA populations, and individuals are expected to solve problems within the
family (Al-Krenawi, Graham, Dean, & Eltaiba, 2004). However, family members often do not
openly discuss mental health problems that their relatives face, based on the fear that it
would devalue their family honour and/or hinder marital prospects (Eapen & Ghubash,
2004; Sewilam et al., 2015). This suggests that more traditional families might seek to sup-
press information about mental health issues among family members. However, it is
unclear how this may vary within the MENA population, and how this variability may be
linked with the use of informal and formal services. It is important to further understand
and characterise how family members may discuss mental health issues, and encourage or
discourage mental health help-seeking in the context of stigmatising cultural attitudes.

For many MENAs, religion plays a key role in coping during times of distress. Much of
the research on the role of religion in coping with mental health distress has focused on
Muslims. Prayer and reading the Qur’an have been identified as common ways to seek
comfort when experiencing emotional distress (Khan, 2006). Religious leaders, such as
imams, are often sought out for support and play a large role in mental health promotion
among Muslim populations, despite their lack of formal training in psychotherapy inter-
ventions (Abu-Ras, Gheith, & Cournos, 2008; Ali, Milstein, & Marzuk, 2005). In fact, imams
often endorse the need for Muslim MENAs to seek formal psychotherapy, particularly
since the events of 9/11 (Ali et al., 2005). While these findings have been consistent
with Muslim MENAs, we know less about whether religious solutions are common
among non-Muslim MENAs, who make up a large subgroup of the US MENA population
(Abu-Baker, 2006). Overall, we know little regarding formal or informal methods of help-
seeking for mental health concerns among MENAs. Given this, it would be beneficial to
understand the perspectives of those who have sought services for mental health pro-
blems despite the barriers they may have experienced.

Currently, there is very limited research available regarding mental health attitudes of
individuals from the larger MENA population, let alone for individuals with specific
national, ethnic, and religious identity configurations. This is due in part to the notable
complexity of conducting research with MENAs in the USA (Amer & Bagasra, 2013). There-
fore, it is difficult to focus on one specific group within the MENA community and recruit

726 M. MECHAMMIL ET AL.

sufficient participants, even in the context of qualitative research. Taking a wide perspec-
tive by focusing on MENAs in the broad sense may in fact be useful for capturing the com-
monalities and variability in experience and conceptualisation of mental health across
various MENA subgroups.

Current study

As described above, limited research is focused on MENAs and additional attention is war-
ranted to improve access to culturally competent services. This study aimed to further
understand attitudes towards mental health and to characterise peoples’ experiences
related to varying sources of informal and formal support that may influence the likelihood
of seeking services. Specifically, this study sought to characterise and synthesise common
cultural attitudes towards mental health from the perspective of immigrant and US born
MENAs who have previously engaged in mental health services in the USA. This will
provide a unique perspective, as these individuals have been exposed to the mental
health attitudes from their culture of origin and have sought therapy for problems
while living in the USA. Since these individuals are navigating between two worlds,
they are in a unique position to share their perspective regarding cultural attitudes
towards mental health from their cultural lens. This novel perspective will better equip
clinicians and researchers to help reduce barriers to treatment and also prepare clinicians
to address these attitudes during treatment (Aloud & Rathur, 2009).

Method

Procedures

Participants
Participants (N = 13) in this study were persons of MENA descent who had seen a therapist
in the USA and were willing to speak about their perception of mental health attitudes
within their communities and about their experiences in therapy. Participants were eligible
for the study if they had seen a therapist in the USA, lived in the USA for at least five years,
and planned to remain in the USA for the foreseeable future. Participants were all between
18 and 40 years of age. Eleven participants were foreign-born and two were second-gen-
eration US citizens. Participants lived in five states across the USA. Table 1 outlines individ-
ual participant demographics.

Research team
The research team consisted of three researchers: the first author is a Syrian-American
female and doctoral student; the second author is a Western-Armenian-American
female who is licensed as a Clinical Psychologist and primarily engages in clinical practice
and supervision within her community; and the last author is a multiethnic (Mexican-
American/European-American) male who is a licensed Clinical Psychologist and an Assist-
ant Professor of Psychology. During the conceptualisation of this research, we gave
thought to the biases we have regarding our own backgrounds and interest in the
research area. Our biases were discussed and considered throughout the process of this

MENTAL HEALTH, RELIGION & CULTURE 727

research to ensure that they were accounted for to improve the integrity of the data analy-
sis and interpretation.

Recruitment
All recruitment and data collection activities were conducted by the second author. Par-
ticipants were recruited through several list-serves, student groups, mosques/churches,
fliers at MENA restaurants/delis, and informal networks. Interested participants contacted
the researcher after seeing a flier (nine participants) or hearing about the study (four par-
ticipants). Initial contact was made via email or telephone. Participants were queried for
eligibility upon initial contact. They were informed about the purpose of the study to
improve multicultural competence in therapy for MENAs in the USA. Most participants
asked about the interviewer’s heritage upon initial contact, and participants were
informed that the interviewer was US born and that her grandfather immigrated to the
USA from Turkey.

Interview procedures
All participants completed two semi-structured telephone interviews that lasted approxi-
mately one hour each and were conducted several days apart. The interview guide was a
list of broad questions with specific probes that could help guide the interview. All inter-
views were conducted by the second author in 2009 and were audio-recorded. Partici-
pants each selected a pseudonym before their first interview and those names are used
in this manuscript. The final sample size (N = 13) was decided based on available resources
and exceeded the recommendation by Guest, Bunce, and Johnson (2006) for a minimum
sample size of 12 to achieve saturation of themes. Despite the heterogenous group
recruited, the interviewer noted that similar topics and experiences were being described
by participants, and no new higher level concepts were being discussed as the sample size
increased above ten. This is consistent with findings from Ando, Cousins, and Young
(2014), which indicated that 12 qualitative interviews are sufficient for representing
higher level concepts. The interview audio recordings were first transcribed verbatim by
a research assistant, and then another research assistant listened to the recordings
while editing the transcriptions. The second author conducted a final check for accuracy
by listening to the recordings while reading the transcripts. Each participant was sent

Table 1. Demographics of participants.
Participant
pseudonym Gender Nationality of origin Ethnicity Religion

Harout Man Lebanon Armenian Christian
Shay Woman Egypt Arab Raised Muslim; converted to Christianity
Sevanah Woman Iran Armenian Raised Christian
Beti Woman Iran Assyrian Christian
Nasim Woman Iran Persian Raised Zoroastrian and Muslim
Ezgur Man Turkey Kurdish Raised Muslim
Arzu Woman Turkey Turkish Muslim
Eshan Man Iran Persian Raised Muslim
Mima Man Iran Persian Muslim
Sophia Woman Iran American Raised Christian
Jon Man Iran Persian Christian
Marie Woman Canada; family is from Lebanon Arab Christian
Sahar Woman US; family is from Iran Persian Baha’i

728 M. MECHAMMIL ET AL.

the transcript from their interview for member checking (Glesne, 2006) and they were
invited to comment upon their reactions to reading the transcripts during a follow-up
phone call or email according to preference.

Data analysis
Deductive thematic analysis was utilised for the coding process, using Braun and Clarke’s
(2006) six steps. After a full read of the interviews by the first author (step 1), theoretically
derived theme labels and codes were developed (step 2). These codes were collated to
themes that provided a nuanced picture of the phenomenon of mental health attitudes
(step 3). These themes were reviewed by the research group (step 4), who then met to
assess the robustness of the coding scheme and to ensure that nuanced differences in
themes were uncovered (step 5). The final report was generated by the first author,
with collaboration of the second and third authors (step 6). This study was approved by
the University Institutional Review Board (Protocol #8436).

Results

Through careful analysis of the interviews, important themes about mental health atti-
tudes emerged. Themes and subthemes are organised below. See Figure 1 for a visual rep-
resentation of codes and relationships between themes.

Lack of understanding

A theme that emerged among most participants was that mental illness was misunder-
stood in their families and cultural communities. For example, Sevanah stated, “Let’s say
a person feels very depressed and they say they can’t get out of bed … people will say,
‘Oh, they, they’re too lazy.’” It became apparent that lack of understanding of mental
health leads to high levels of stigma, as indicated by Nasim’s comment, “So my dad

Figure 1. Thematic map showing the relationships between main themes (ovals) and subthemes
(rectangles).

MENTAL HEALTH, RELIGION & CULTURE 729

was saying that at that time he didn’t understood that [his friend had] test anxiety … it’s
really difficult for him to concentrate … and he constantly makes fun of his friend”.

Stigma of symptoms and treatment

Nearly all participants shared that people who suffer with mental illnesses experienced
both perceived and self-stigma within MENA families and communities.

Perceived stigma
Participants discussed experiences of perceived stigma, which seem related to the pre-
vious theme of lack of understanding, as many comments were embedded within a
broader issue of community and family members not having education regarding
mental illness symptomology. For example, Nasim stated,

I remember people saying, ‘Oh they’re just crazy.’ So overhearing that word a lot that people
are just crazy, there’s something wrong with them. That’s the attitude I had when I came to the
US, it’s just like there’s one thing you’re either sane and you’re ok … you’re normal, or you’re
crazy.

Shay shared that her father’s reaction to her depression and suicidality was to say, “You are
an idiot. Don’t be stupid. Get over yourself.” This illustration is made more poignant by the
fact that her father was a medical doctor trained both in the Middle East and in the USA.

Along with stigma regarding symptoms of mental illnesses, participants shared experi-
ences of stigma related to treatment for mental illnesses. Participants shared experiences
of family members being critical of their decision to attend therapy, and community
members stigmatising those who do decide to seek help. Sevanah shared, “Of course
there’s a big stigma attached to it … both in my family and where I live and even
saying, just going to therapy … are considered very bad”. Family members also belittled
individuals’ decision to go to therapy, expressing that seeking professional help is only
for those who are “weak”.

Self-stigma
Participants also shared experiences of self-stigma that reflected how they may have
viewed themselves when dealing with mental illnesses. For example, Arzu shared, “I
was weak and I couldn’t deal with it … kind of, you know, feel[ing] ashamed.” Jon
elaborated,

There’s a feeling like, not that you have to deal with your problems, but I think it’s much more
like, you should just tough it out … especially among men I think it is more prevalent that if
you’re feeling sad, that’s kind of a weaker emotion, you shouldn’t really care or you shouldn’t
pay attention to it … that’s why I think it is difficult for some people to say ‘well, I have a
problem’.

As a result of these experiences with stigma, individuals often kept things private to avoid
being shamed. Participants felt very resistant to admitting they needed help, and when
they sought help, they felt ashamed for doing so. Sahar explained, “If you are seeking
help, then you aren’t a strong person or there’s just this misconception that you can’t
handle your life and so somebody else has to help figure it out for you”. They also kept
their experiences a secret from others, as exemplified by Arzu, “I don’t tell my friends

730 M. MECHAMMIL ET AL.

that I’m going to therapy. It’s a private thing, but at the same time I think I still feel a bit
ashamed … not ashamed, but, you know, not comfortable”.

Role of family

The next major theme relates to the significant role of the family in responding to mental
health concerns. Over half of the participants indicated that the family took responsibility
for addressing mental health concerns, and that families typically avoided discussion of
mental health outside of the family.

Family support
Most participants discussed that the family, rather than the individual, would be respon-
sible for helping the person to find relief from distress. For example, Arzu shared, “The
family would say, ‘This is our problem, we have to solve this together. You are not on
your own. You are together in this’”. Individuals emphasised that families would find it
their duty to make sure people were supported, and that the family is the first avenue
for seeking help. In Sahar’s experience, she explains, “I think our culture, with a seemingly
a very tight knit group of people, families do tend to really try and go out of their way and
help people”. Shay elaborated, “You don’t go out of your family for an issue, I mean, every-
thing is a family thing. And if it can’t be resolved in the family then it’s irresolvable”.

Role of elders
In addition, family elders, in particular, were the ones who held most responsibility. Elders
were described as the members of the family who had the knowledge or abilities to help
someone who was struggling. When asked who took charge for helping, Shay stated, “the
most capable person in the family. Usually that would be the father. Like in my family’s
situation, if that had happened, that would have been put on my father”.

Avoiding discussion
Along with helping to support individuals, participants discussed that mental illness was
not discussed outside of the family or within the family. Sophia explained this by
saying, “I would say that mental illness and psychological distress were thought of as a
reality, but were never discussed with the children”. This lack of discussion likely leads
to increased stigma and shame associated with mental illness.

Participants also expressed that they learned later in life that a family member had
suffered from mental illness, and often times the family would go out of their way to
ensure that their illness was not known to others. A person with mental illness might
be nurtured and hidden away within the home, and not directly discussed within families.
Nasim recalled an aunt with depression and explained,

I remember her not feeling well … I remember nobody wanted to talk about it I remember she
would lock herself in the room … She didn’t want to come out she just wanted to sleep the
entire time and I remember my mom just ignoring that like not having any thought about it
and [my mom] kept saying, “She’s not there”.

Based on participant responses, it is likely that the act of keeping issues within the family is
done as an effort not to tarnish others’ perception of them or the family as a whole.

MENTAL HEALTH, RELIGION & CULTURE 731

Role of religion

Religion was also discussed as both a cause and solution for mental illness. The partici-
pants in this study come from an array of religious backgrounds, indicating that these
themes are not specific to individuals from one religious group.

Religion as a cause
Two participants indicated that they recalled others in their family believing that mental
illnesses were caused by a spiritual being or resulting from insufficient religious practice.
Harout stated, “I think if you’re hallucinating they probably just think of it as very spiritual
… it would have to be demonic”. Shay explained that in her family/culture, mental illness
was viewed as consequence of giving in to temptation from Satan. These two individuals
have different religious backgrounds (Harout identified as Christian, Shay was raised
Muslim), so it is possible that this theme may generalise across religious identities for indi-
viduals with family ancestry in the MENA region. This theme, although not as common,
may also help to explain high levels of stigma related to mental illness in MENA culture,
given the strong emphasis on religion in the region.

Religion as a solution
Six participants discussed religious solutions to mental illness and/or psychological dis-
tress. Harout and Arzu noted that family members would pray for a mentally ill person.
Ezgar indicated that older people would “try to treat him/her in some religious ways”.
Shay noted that one would “ask God for the ability to continue reacting normally in
their life … to continue doing what they were doing before”. Despite an evident lack of
understanding of mental health issues among MENA communities, this theme illustrates
religion and faith as a coping mechanism that is commonly used, highlighting the
strengths that many MENA families are able to leverage.

Discussion

The findings of this study suggest that MENAs report a common set of traditional mental
health attitudes that influenced their conceptualisation of their own mental health and
their decision to receive services. It suggests that current Western views of symptoms of
and treatment for mental illness do not seem well understood, and are therefore stigma-
tised, in many MENA families. Family and religion also appear to play a large role in under-
standing and responding to mental illness. While many of these experiences may mirror
those of other US individuals, this study highlights nuanced perspectives of MENAs who
have sought therapy. This perspective is unique, as it allows us to understand the experi-
ence of individuals who have been exposed to more traditional attitudes yet have made a
decision to seek professional care for their concerns.

We identified a prominent theme in which individuals discussed that mental health was
not well understood and was stigmatised in their families and communities. It is important
to acknowledge that participants in this study have sought psychological services for their
symptoms and consequently have had more exposure to more Western conceptualis-
ations of mental health, which their family members may not have been exposed to.
Families often did not know what therapy entailed, did not understand the role of

732 M. MECHAMMIL ET AL.

symptoms in a person’s daily functioning, and expressed notable negative attitudes
towards people with mental health problems. Other studies have noted that many
MENAs lack the knowledge necessary to identify a mental health problem (or the cause
of it), which may be one reason individuals are labelled as “crazy” or are hidden from
others (Sewilam et al., 2015; Taghva et al., 2017). This may be one explanation for the per-
ceived lack of understanding among family members, which likely creates a feedback loop
between perceived stigma from the broader community and self-stigma experienced by
individuals. Nevertheless, stigmatising mental illness commonly leads to minimisation of
psychological problems and a lack of awareness of psychological services (Zane,
Morton, Chu, & Lin, 2004). These factors seemingly can lead to increased psychological
problems and decreased support for receiving needed mental health services. MENAs
may therefore wait to seek psychological services until the severity or chronicity of their
problems is much worse. The novel task of finding a therapist may be even more
difficult to accomplish in the context of greater psychological distress. It is less clear
why individuals in this study felt motivated to seek services despite these high levels of
perceived stigmas within their communities. It is possible that individuals in this study
were more acculturated, exposed to more Western views of seeking help, or were
highly distressed, which helped mitigate the high levels of stigma from their communities.

Another factor that may contribute to perceived and self-stigma is the role of honour
within MENA families. Individuals in this study often expressed that it is typical to “keep
it in the family” when one is suffering from mental illness, out of fear of bringing shame
to the family (Abu-Ras, 2016). The role of the family structure seems to also be maintaining
stigma, as MENAs suffering from mental illness may be labelled negatively by those closest
to them. While honour was not directly discussed by participants, some discussed that
families addressed mental illness by ignoring it and hiding the sufferer from the outside
world, which may be tied back to the role of honour in MENA culture. Traditionally,
seeking services is seen as a reflection of the family’s inability to cope and support
those around them (Al-Krenawi & Graham, 2016), so this response appears to be an
effort to protect the family name (Nassar-McMillan, Nour, & Al-Qimlass, 2016). Therefore,
the combination of mental illness stigma and a focus on family honour likely presents a
notable barrier to seeking formal mental health services. A possible solution for navigating
this barrier in order to increase access to services is to offer mental health services as part
of primary care, using an integrated care approach.

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