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

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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

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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

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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

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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 Help- 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

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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 Helpant, and then another research Helpant 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

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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).

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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

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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.

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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

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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. If families are able to access mental health care during general health visits, it may also help them rethink their attitudes of mental health, while not threatening family honour. However, some participants also described supportive responses to psychological distress from immediate family members. Therefore, it is important to acknowledge and understand the variability within family responses. It is unclear in what situations families are more likely to express support as opposed to shame or stigma in regard to mental health symptoms, and more research should be done to further understand this family process.

Indeed, the emphasis on family in MENA culture (Al-Krenawi & Graham, 2016) posits a unique opportunity to engage family members in treatment of those suffering with mental illnesses in a way that may empower, rather than further stigmatise, the individual. Con- sidering the important role of the family as a source of social support for one’s emotional well-being (Aloud & Rathur, 2009), psychoeducation and anti-stigma interventions can be tailored to educate family members on the causes, treatments, and resources available to

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those who need professional help (Taghva et al., 2017). Further, given the prominent role of elders in MENA family systems, interventions can also be tailored to include individuals who are looked at as “the head of the family” to help individuals seek recovery.

Consistent with other research, religion was identified as often playing an important role in MENA families’ understanding mental illness, including using religion as a solution to these problems (Khan, 2006). It is important that professionals engaging with MENAs understand the role of religion in their lives and in their conceptualisation of their current concerns. More traditional families may align more with religious explanations and solutions to psychological distress. It is possible that these alternative explanations are utilised as a way to make sense of something that is not discussed or learned due to the broader cultural stigma regarding mental health. While religious coping can serve as a source of resilience for many MENAs, many may need more support than this (Abu-Ras, 2016). Given that imams have outwardly expressed the need for MENAs to seek professional help, there is opportunity for religious leaders to be used as resources to help empower individuals who are suffering from mental health problems (Ali et al., 2005). Therefore, it appears appropriate for mental health providers to engage with reli- gious leaders to help educate families of mental health/illness.

Limitations

Participants in this study self-selected by responding to requests to participate and may differ in important ways from persons who would not choose to participate in such research. In particular, individuals seemed motivated by a desire to discuss their experi- ences with mental health problems within their family and culture, and by an interest in helping others. All of the study participants had seen therapists in the USA and may differ in their mental health attitudes from those who have not sought mental health treat- ment. This was appropriate as the initial study sought to provide information for therapists who may encounter MENA clients. Further, this study did not explore MENA ethnic identity directly. It was discussed often, but was generally implied as a result of the researcher’s understanding of and connection to the topic. Interview questions did not assess this topic area and participants were not asked to discuss how they labelled themselves cultu- rally, to describe their ethnic identity, or acculturation to the US culture. Many of the par- ticipants (or their families) were from Iran, with fewer from Lebanon, Turkey, and Egypt. Therefore, only a few of the countries under the MENA umbrella were represented in this study. In addition, only two participants were born in the USA and therefore the nuances between foreign-born and US born individuals were not captured in great detail. Lastly, the use of phone interviews may have limited the ability to make behavioural observations of the participants, which are often an important part of qualitative method.

Future directions

Future research should explore the definition of family in MENA systems, as everyone in this study talked about family, but the interviews did not elicit descriptions of who was included or the relative impact that different family members may have on behaviour. It is also important that research more closely addresses the role of family honour in contri- buting to mental illness stigma among MENA families. Future research should also aim to

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understand facilitators for seeking support despite high levels of stigma within MENA communities, as this study was not able to address this issue. Lastly, it is possible that indi- viduals of different acculturation levels may have different attitudes regarding mental health, and this should be studied further. In addition, it is also vital that further research is done to study ways to reduce the stigma in MENA communities, with a recommended emphasis on psychoeducation and community awareness campaigns.

Conclusion and clinical applications

MENA cultural identity is complex and often cannot be defined solely in terms of ethnicity, religion, or nationality; instead, it is often defined by each of those qualities with individ- uals placing different emphasis upon each category. Despite the diversity of the sample, participants seemed to discuss similar experiences and viewpoints in their interviews. The findings of this study suggested that there are common mental health attitudes held by MENAs, which may directly relate to the provision of psychological services for this group. In particular, practitioners and policy makers should address stigma of mental health issues in the community through public health campaigns and psychoedu- cation. Providers can also use these results to assess mental health attitudes held by clients, and others within their community. There may also be opportunities to leverage family elders and religious leaders and faith practices to supplement and enhance therapy. These strategies can facilitate more adaptive mental health attitudes and support networks that can be used to achieve recovery from mental health problems.

Disclosure statement

No potential conflict of interest was reported by the authors.

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Abstract
MENA region and population
Mental health risk and attitudes
Sources of support for mental health
Current study
Method
Procedures
Participants
Research team
Recruitment
Interview procedures
Data analysis
Results
Lack of understanding
Stigma of symptoms and treatment
Perceived stigma
Self-stigma
Role of family
Family support
Role of elders
Avoiding discussion
Role of religion
Religion as a cause
Religion as a solution
Discussion
Limitations
Future directions
Conclusion and clinical applications
Disclosure statement
References