CALIFORNIA STATE UNIVERSITY, NORTHRIDGE Mental Health And

Home , Middle Eastern Americans

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

Mental Health and Middle Eastern Cultural Identity

A graduate project submitted in partial fulfillment of the requirements

For the degree of Master of Social Work

Talin Tina Gharibian

May 2019 The graduate project of Talin Tina Gharibian is approved:

______Dr. Susan Love Date

______Dr. Wendy Ashley Date

______Dr. David McCarty-Caplan, Chair Date

California State University, Northridge

ii Dedication

To my mother, Mary, and my father, Zareh: thank you for your unconditional love, support, and strength. To my family: thank you for always being there for me, and for inspiring me to become a social worker. To my beautiful friends: thank you for always believing in me and providing a safe space for growth. And to my community: thank you for your support and extraordinarily inspiring resilience. Finally, thank you to my advisor and mentor, Dr. McCarty-Caplan, for consistently fostering my passion for research and wholeheartedly supporting my dedication to making this project a reality. It is all of your unwavering encouragement that carried me through moments of difficulty or doubt. Thank you.

I would like to dedicate this work to my grandmother, Zvart: my deepest source of inspiration and courage.

iii

Table of Contents

Signature Page ii

Dedication iii

Abstract v

Chapter 1: Introduction 1

Aims and Objectives 4

Chapter 2: Method 6

Participants 6

Measures 6

Research Design 7

Procedure 8

Chapter 3: Results 10

Sample 10

Coding 10

Themes 11

Chapter 4: Discussion 15

Limitations 17

References 19

Appendix A: Interview Questions 21

Abstract

Mental Health and Middle Eastern Cultural Identity

Talin Tina Gharibian

Master of Social Work

Purpose: Focusing on the unique narratives of Middle Eastern Americans can help clinicians understand the dynamic relationship between cultural identity and mental health and substance use issues. The purpose of this work is to expand our understanding of the specific needs of Middle Eastern Americans in mental health research and practice.

To do so, this study utilized a qualitative exploratory research methodology in order to examine the culturally influenced mental health experiences and attitudes of this population. Researchers recruited 15 participants of Middle Eastern descent for in-depth interviews. Data was analyzed utilizing thematic content analysis methodology.

Researchers developed 12 codes, which ultimately resulted in 5 key themes: denial, lack of awareness, stigma and shame, collective identity, and resistance. It is hoped that this research will inform our understanding of the intersection between mental health and

Middle Eastern cultural identity, in order to expand culturally competent and unbiased treatment interventions.

Search terms: mental health, substance use, cultural identity, ethnic identity, Middle

Eastern, Middle Eastern American, SWANA, Arab American, cultural competence.

v Chapter 1: Introduction

The existing body of evidence suggests that the health of Middle Eastern

Americans may differ from that of other minority racial and ethnic groups in the US, and that exposures specific to this ethnic group (such as immigration, acculturation, and discrimination) may be critical indicators of illnesses among this population (El-Sayed &

Galea, 2009). Moreover, immigrants and displaced peoples face stressors that are 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, Ventevogel & Rees, 2017).

Middle Easterners are one of the fastest growing immigrant groups in America: while the size of the legal and illegal 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, Khater & Culang, 2016). The Middle Eastern American population 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 in the United States (Cumoletti & Botlova, 2018). Due to the population’s growing presence in this country, the numbers who seek health and mental health treatment has also increased (Lipson & Meleis, 1983). The global crisis of displacement

1 continues to grow, along with the number of refugees and Middle-Eastern immigrants seeking a new home in the United States. As such, treatment providers must understand the unique needs of this expanding population.

There are a variety of terms that refer to same population: MENA (Middle

Eastern North African), SWANA (Southwest Asian North African), Arab, Middle

Eastern. Middle Eastern communities are typically lumped together by politicians and the general public as “Arabs” (Arab and Other Middle Eastern Americans, n.d.). The category encompasses over 20 minorities and ethnicities, including: Lebanese,

Palestinian, Syrian, Egyptian, Armenian, Iranian, Libyan, Moroccan, Kurdish, Afghan, and Iraqi. Despite greater attention to Middle Eastern Americans in the media and public discourse in the US, there is troublingly limited research about the health and well-being of this population (El-Sayed & 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, Byrd,

Saez, & Manly, 2010). However, relationships between Middle Eastern patients and

Western health care professionals are often troubled by mutual misunderstanding of culturally influenced values and communication styles (Lipson & Meleis, 1983). Thus, effective treatment necessitates awareness and understanding of unique cultural dynamics. According to a 2011 study, cultural identity and family dynamics played a critical role in the therapy experiences of Middle Eastern persons: the therapists’ ability to understand cultural identity and family dynamics was related to treatment acceptance and efficacy (Boghosian, 2011). Moreover, Middle Eastern Americans increasingly live in a hostile socio-political environment fueled by xenophobia, creating negative

2 stereotypes and heightened discrimination faced by this community in particular. Anti-

Middle Eastern and anti-Arab sentiment is on the rise particularly during the Trump era.

For example, in a research paper titled, “Making America Hate Again? Twitter and Hate

Crime Under Trump,” University of Warwick researchers Karsten Müller and Carlo

Schwarz explore how anti-Muslim hate crimes recorded by the FBI are in fact correlated to how Trump tweets about Islam. Such an environment both negatively impacts the mental health of these individuals, and has implications for culturally competent and unbiased counseling interventions that are critically needed (Soheilian, 2012).

It is clear that Middle Eastern Americans suffer health disparities along with other racial minorities. Recent waves of immigrants and refugees from the Middle Eastern region face compounding stressors, given that many have fled war, political instability and violence. Public perception and policies can make their acculturation more difficult than other ethnic groups. Finally, many Middle Eastern populations have experienced collective trauma, such as the Armenian Genocide and occupation of Palestine. These communities are continually impacted by the ramifications of the collective trauma they experienced, which may be transferred to subsequent generations through genetic indicators and poor mental health outcomes.

Despite this reality, increased visibility of Middle Eastern and Arab American health issues is critically needed. Empirical research on Middle Eastern Americans and counseling competence remains neglected (Soheilian, 2012). The impact of stigma, discrimination, and stress has been studied in other distinct groups in the United States, such as African-American and Latino populations. This is not the case with Middle

Eastern Americans. Despite a large demographic presence, there has not been a single

3 prospective study examining the health needs of this population (Abuelezam, El-Sayed,

& Galea, 2017). Research concerned with health inequalities between population groups has been dominated by studies concerned with race-based disparities, instead of ethnicity

(El-Sayed, Tracy, Scarborough, & Galea, 2011). There is no “checkbox” for Arab/Middle

Eastern origin in medical and public health studies, and no specific identifier on the US

Census. Because of this, there is limited research about the health of this community in the public health literature (Abuelezam et al., 2017). As a result, Middle Eastern and

Arab populations in the United States are essentially rendered invisible within scientific literature on this topic.

Aims and Objectives

Culturally competent interventions are critically needed within this population.

This study addressed this need by examining the relationship between mental health and cultural identity among persons of Middle Eastern descent. To do so, this study will utilize a qualitative research methodology in order to specifically examine the culturally influenced mental health attitudes and experiences of this population. The purpose of this work is to expand our understanding of the specific needs of Middle Eastern Americans in mental health, in both research and practice, in order to expand culturally competent treatment and improve their quality of care.

4 Chapter 2: Method

Participants

This study included a sample of 15 Middle Eastern American adults. Participants were recruited through snowball sampling, convenience sampling and social media

(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. 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 (though a mental health diagnosis was not required) and (3) of Middle Eastern,

Arab or Southwest Asian North African descent. Eligible ethnicities within this population included but were not limited to: Armenian, Iranian, Syrian, Lebanese,

Afghan, Egyptian, Iraqi, Turkish, Palestinian, Emirati, Assyrian, Pakistani, Jordanian,

Qatari, etc. Participants were selected regardless of gender, ethnicity, socioeconomic status, sexual orientation or physical ability status. However, all participants were proficient in the English language as interviews were conducted in English only.

Exclusion occurred when participants were (1) not over the age of eighteen (2) unwilling to discuss mental health or substance use issues or (3) not of Middle Eastern descent.

Participants were also excluded if they did not provide informed consent to participate in the research study. Particularly vulnerable groups, such as pregnant women, incarcerated adults, and the cognitively impaired were also excluded.

Measures

As a qualitative study, this study focused on the personal views and experiences of each participant, as they ultimately related to cultural identity and mental health.

5 Researchers used a 14-question interview to measure relevant variables. The open-ended interview questions were written by the researcher, and were created based on the research question and the existing literature. To see the interview questions please see

Appendix A. In addition to the 14 interview questions, participants provided additional demographic information including: age, sex, ethnicity, religion, self-reported mental health issues, self-reported substance use issues, and mental health status or substance use issues of family members.

Primary variables examined included Middle-Eastern cultural identity and mental health or substance use. Additional variables examined included family dynamics, community dynamics, cultural norms and 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, one’s understanding of mental health and mental health conditions can be subjective, varying from individual to individual. Moreover, conceptualization of “mental health” may be impacted by cultural factors. As a result, participants were asked to define what mental health means to them, and to describe their individual understanding of mental health struggles. Similarly, in order to measure cultural identity, participants were asked to discuss their own conceptualization of culture, and how important it is to identity and perspective within themselves and their community. Additionally, in order to explore the relationship between both of these variables, participants described how their experiences with and views of mental health was informed by their unique Middle Eastern cultural identity.

Research Design

6 This exploratory qualitative study gathered a sample of adults of self-identified

Middle Eastern descent. Data was collected from semi-structured in-person interviews, conducted from January through April of 2018. This study focused on the participant’s culturally influenced mental health attitudes and experiences, and the meaning of these experiences to the participants themselves. Thematic Content Analysis was utilized to evaluate the data gathered. Analysis resulted in emerging themes and patterns regarding the unique challenges and perceptions of mental health among this population. These themes determine the specific needs of Middle Eastern Americans in mental health. The

California State University, Northridge Institutional Review Board approved this study, known as IRB-FY19-105.

Procedure

All data were collected between February 2019 and May 2019. The sample was drawn from a random sample of Middle Eastern adults living in Los Angeles County, in the United States. Participants were recruited exclusively electronically, using (1) social media posts on Facebook and Instagram through the researcher’s personal social media network (2) social media posts on Facebook through the public pages of relevant groups or organizations. All recruitment materials (electronic flyers or posts) included a brief description of the study, link to an online eligibility survey, and a means of contacting the

Principal Investigator. Within these recruitment materials, potential participants were provided a link to an initial survey. Once they clicked on this link, participants answered three questions to determine eligibility, based on the three aforementioned inclusion criteria. This screener survey was hosted to Qualtrics electronic survey program and occurred only one time. Upon meeting each of the three eligibility criteria, participants

7 were eligible to participate and were provided the researcher’s contact information and were directed to contact the researchers in order to schedule an in-person, individual interview. Interviews were conducted at public libraries or coffee shops in the Los

Angeles area. At the interview, the Principal Investigator discussed informed consent, obtained participant signature, and provided a copy of the consent form. Study participants also consented to the audio recording of the session. Following consent, participants were interviewed utilizing 14 open-ended questions, related to the primary research question. The duration of each individual interview was between fifteen minutes to one hour. Each interview was audio recorded using a digital audio recording device.

Compensation in the form of a $20 Amazon gift card was provided upon conclusion of each interview. The total length of subject participation varied based upon the individual time between eligibility determination, initial contact and scheduled interview. All data gathered through face-to-face interviews was cleared of any personal identity markers and subsequently transcribed. Upon transcription, data was analyzed to explore relevant themes and trends. The audio recordings were destroyed immediately after transcription.

8 Chapter 3: Results

Sample

A total of 15 individuals of Middle Eastern descent participated in this study, and demographic factors varied. All participants were between 20 to 35 years old. Of the participants, 9 were women and 6 were men. On the basis of religious affiliation, 3 were

Christian, 4 were Muslim, 3 were Atheist/Agnostic, and the remaining 5 identified as

Other. Middle Eastern ethnic groups included: 9 Armenian, 2 Egyptian, 2 Iranian, 2

Lebanese, 2 Afghan, and 1 Iraqi. Some of the participants had overlapping ethnic identities. 80% of participants described self-reported mental health issues or official mental health diagnoses. 20% of participants described self-reported substance use issues or official substance use diagnoses. 13 of the 15 participants (about 87%) described a family history of mental health or substance use issues. All described personal experience with mental health or substance use issues, either of themselves or loved ones.

Coding

The researchers began familiarizing themselves with the data by reading through all of the interviews twice. Relevant and important segments of data were identified and assigned codes within the interviews during these rounds of reading. More than 40 codes were identified in the first round of coding. These were subsequently narrowed to 24 codes in the second round. The researchers observed significant patterns in the data that were scrutinized in regard to the research question. Identified codes included: pride, personal reputation, family reputation, social propriety, undiagnosed conditions, honor, negative familial and communal view of mental health issues, negative familial and communal view of substance use, negative familial and communal view of treatment,

9 isolation, invisibility, positive view of treatment, openness to treatment, family unit, cultural pride, importance of cultural competence, generational divide, weakness, avoidance, secrecy, insular community, resilience, limited knowledge, negative treatment experience.

Themes

Following the coding process, the 24 codes were further organized and categorized into 5 primary themes: denial, lack of understanding, shame and stigma, collective identity, resistance.

Denial. From the data presented, the researchers found a pattern of participants describing denial. This theme refers to denial of mental health or substance use issues by the participant’s family members or cultural community. Nearly all participants described experiences regarding this theme. Some participants described how other family members denied the existence of the participant’s own mental health or substance use issues. Most examples concerned “less severe” mental health issues such as depression or anxiety, which were more commonly denied by family members. For example, according to one participant,

“A big struggle in my immediate family, basically between me and my dad was getting him to a point where he understood that I wasn't making my depression up to avoid studying. And that I wasn't just making excuses for being in a bad place. That was a tooth and nail kind of fight. I think it took things getting really, really bad for me personally for him to recognize what kind of damage was being done by his continued refusal to acknowledge the reality of that mental health issue.”

Other participants described how family members denied the existence of their own mental health or substance use issues. Many of these referred to family member’s denial of his or her own alcoholism, post-traumatic stress disorder, or depression.

10 Tobacco was also denied as substance use. Others described their community’s denial of the existence of mental health or substance use issues within the ethnic community.

Lack of understanding. The researchers discovered lack of understanding or awareness as a consistent theme described by each of the participants interviewed. Nearly all participants described a general lack of understanding of mental health or substance use issues within the cultural community. According to one participant,

“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 think honestly with more information, people will understand better. I don't think it's understood well in the community cause it's never taught in the community or in the family.”

Most described how their community’s view of mental health issues was either false or shallow. This was even more so the case concerning addiction or substance use.

Most described how their family’s understanding of mental health issues was similarly limited. Some stated their family members viewed addiction as simple personal choice.

Others stated their family’s understanding of mental health issues was that they are due to superstitious causes. Overall, nearly all participants attributed this lack of understanding to a general lack of public discourse: “The fact that there's no conversation around it is what makes it difficult to understand.”

Shame and stigma. From the data that was analyzed, the researchers noticed patterns in terms of shame and stigma in participant experiences or views. Every one of the participants described shame and stigma as significant factors in their mental health or substance use experiences. Most participants described stigma to treatment within their families and communities: “My mom refused to go see a therapist for PTSD because of the stigma associated with it.” All participants described how mental health and

11 substance use issues were stigmatized heavily within their family and cultural community. According to one, “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.” Most participants described shame as a barrier to admitting, discussing or seeking treatment for mental health issues: “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.” Throughout the interviews, many participants described the particularly relevant role of shame and stigma in terms of substance use issues. According to one participant,

“The biggest barrier to having conversations about it is shame, because it's almost even shameful to have conversations about it. You don't talk about it. It's the elephant in the room. 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 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.”

Collective identity. The researchers noticed a consistent pattern of participants describing collectivism or collective identity as a factor. This includes collectivism within the culture or community, collective identity within the family, and the importance of the family unit. Most participants described a tendency towards the larger family or community unit, often at the expense of an individual’s mental health. For example, one

12 participant stated, “We don't have a culture of really engaging with psychology on an individual basis. I think there's a stronger focus on the family unit or the community and safeguarding peoples' reputations and saving face and being an upstanding, respected member of society who's viewed in high esteem by the neighbors and the relatives.”

According to another participant,

“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.”

Many participants also described how an individual’s mental health or substance use issues are impacted because they are often tied to the family’s reputation within the collective community: “I think for Afghans the biggest value is honor. Because the family is so communal, one person's actions reflect on everyone in the family.”

Resistance. The researchers identified a common theme of resistance among the data analyzed. Resistance may be defined as an opposition to or refusal to accept mental health or substance use issues, diagnosis or treatment. Many participants described resistance among their family members particularly to treatment. For example,

“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.”

Other participants described resistance to treatment that exists because the discussion of mental health issues and the utilization of treatment are seen as a sign of weakness. According to another participant,

“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. They never asked for help, especially men. I think this is because culturally, we

13 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.”

Throughout the study, most participants described resistance to discussion, diagnosis and treatment within both their familial unit and larger cultural community. For example, according to another participant,

“There is an unwillingness to like address these problems. I think that mental health issues are prevailing in Middle Eastern culture, and many cultures that are like heavy on their metaphysics. Cultures that have been through wars and genocide, traumas that keep us bonded. And because of that we have a lot of these mental health issues. But I don't think a lot of people are willing to address it. And that's why it's so prevalent, because we are unwilling to look at someone in our culture with a mental health issue, and say something constructive or try to rehabilitate. We just kind of like brush it aside or we don't want to deal with it. This is also true in my family. 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.”

Participants also described resistance as a result of pride, within both the familial unit and cultural community. Rooted in pride, this resistance to mental health issues often results in silence. For example, according to one participant,

“I think that within my immediate family something that we all deal with in some form, because of the cultural beliefs and practices around it, is silence. 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 moved through it. And that can be said for the broader cultural beliefs. And then the way that it translates within my own family system is that there is a lot of silence around 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. You are choosing to act out or you're choosing to drink.”

14 Discussion

The primary findings of this research reveal 5 themes in the data that allow for an answer to the primary research question. These themes allow us to more thoroughly explore the unique relationship between Middle Eastern identity and mental health issues.

Overall, certain ideas were prevalent throughout the various participant interviews.

Common ideas revolved around pride, propriety, honor, and reputation. As such, clinicians should be acutely aware of the prevalence of these ideas within Middle Eastern communities, and the impact they may have on an individual’s experience with mental health or substance use issues.

All participants described negative familial or communal views of mental health issues, and particularly substance use issues. This suggests the importance of breaking negative stereotypes, perhaps through increased awareness and normalization. All participants also described invisibility of various forms: undiagnosed conditions, denial of mental health or substance use issues, a general lack of knowledge, a lack of thorough or accurate understanding. This similarly affirms the importance of increased awareness and understanding through psychoeducation, within both family units and larger communities. Increased awareness in both spheres is critically needed.

Many participants described family members with undiagnosed conditions, particularly older family members. As described, this was often due to denial, resistance to the discussion of issues, or resistance to treatment. It is important to promote a more nuanced discussion of treatment, in order to minimize negative stereotypes and de- stigmatize both therapy and medication treatment. Moreover, many participants described a familial view that mental health and particularly substance use issues are the result of

15 Westernization/Americanization and thus a loss of cultural values. This is particularly significant for Middle Eastern Americans suffering from mental health and substance use issues, who would seek treatment from American clinicians, which most often uses

Western modalities.

Practice Implications

All participants stated their cultural identity was important to them, and nearly all stated it is important for a clinician to understand their cultural values and norms. Thus, it is acutely important for non-Middle Eastern clinicians to be aware of the importance of cultural competence, and to be sensitive to cultural values and norms they may not be familiar with. In fact, some participants described negative therapy experiences in which the provider lacked cultural understanding, particularly in regards to the participant’s culturally influenced communication styles and family structure.

Despite these negative experiences linked to a lack of cultural competence, all participants maintained an overall positive view of and openness to treatment. Cultural competence on the part of the clinician could make the difference in these participants’ therapeutic experiences. This is particularly important, as this younger generation of participants appears to be more likely to engage in treatment to begin with. Relatedly, nearly all participants described a “generational gap” in communal and familial views of mental health or substance use issues, including a significantly greater awareness of and openness to these issues in the younger generation and diaspora.

Moreover, awareness of this gap among clinicians might more positively impact therapeutic engagement of family members. It also stresses the importance of promoting awareness and culturally competent interventions among older Middle Eastern patients.

16 Many participants described the idea that resilience was expected of them from their family and community because some of their fellow family and community members survived traumas such as war, displacement, and genocide. This stresses the importance of reframing mental health and substance use issues as legitimate struggles as opposed to irrelevant and invalid weaknesses, and the importance of harnessing that cultural emphasis on strength and resilience to better serve the patient’s own resilience in the therapeutic process. Themes linked to collectivism could be utilized as protective factors, via increased community awareness and the involvement of the family unit in treatment.

Limitations

Some important limitations existed within this research, and are worth describing.

For example, the sample size included 15 individuals, which is a small representation of the large Middle Eastern American population, particularly in Los Angeles. Although the data obtained from these 15 Middle Eastern adults provided significant insight into their shared cultural lived experiences, there are many perspectives left unheard, particularly of other ethnicities and age ranges. All of the participants were under the age of 35, which does not account for the views and experiences of older Middle Eastern

Americans, who may be equally if not more so be impacted by these themes and issues.

Moreover, a large proportion of the participants were Armenian and so other cultural identities were not as thoroughly represented. This lack of equally represented ethnicities is a significant limitation as this study specifically aims to examine cultural identity.

Unfortunately, these factors may skew the results, which decreases the reliability of these findings. Subjective experiences described by study participants might make it difficult to

17 replicate this study. The time consuming nature of individual interviews and delayed approval from the IRB prevented the recruitment of a large sample size, or more culturally inclusive and diverse perspective.

Conclusion

Overall, researchers concluded that the themes identified are likely significant barriers for individuals with mental health or substance use issues within these cultural communities. Future researchers and clinicians may benefit from this knowledge and expanded understanding of the unique needs and experiences of this population. A more nuanced understanding may support future research and practice that will help reduce the impact of these barriers for Middle Eastern Americans.

Middle Eastern Americans are impacted by a two-fold injustice: they face great stressors and increased rates of mental illness, while simultaneously suffering from decreased levels of visibility and cultural understanding. Ensuring that they receive improved quality of care requires studies to understand their needs and the long-term impact of political instability and discrimination on this population. It is critical to expand literature and culturally competent treatment with persons of Middle Eastern descent, which is currently very limited. It is hoped that further exploration of the unique and complex relationship between Middle Eastern cultural identity and mental health will promote culturally competent treatment and more unbiased interventions.

18 References

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20 Appendix A

Interview Questions

Demographic Information:

Age: Sex: Ethnicity: Religion: Self-reported mental health issues: Self-reported substance use issues: Family history of mental health or substance use issues:

Interview Questions:

1. In your opinion, what is mental health and mental illness? 2. In your opinion, what is addiction? Do you feel like addiction is a mental health issue? 3. Do you have personal experience with mental health issues or addiction? 4. How are mental health issues viewed in your family and your community? 5. How is addiction/substance use viewed in your family and in your community? 6. Is your cultural identity important to you? What makes up this identity? 7. How do you think your culture’s values and norms impact mental health or substance use issues? 8. 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? 9. What are your views of mental health or substance use treatment? Do you or your family members feel comfortable accessing treatment? 10. Have you or your family accessed treatment? How would you describe the experience? 11. What do you think prevents treatment utilization for you and your community? 12. How would you describe your level of trust in professional treatment? 13. 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? 14. How do you think a shame and stigma impact mental health or substance use issues in your family and community?