visibly invisible:
the plight for Middle Eastern and North African
representation in clinical research

katrina rbeiz

After conducting multiple clinical assessments and taking psychological surveys online, I kept coming across the same issue of ethnicity and race being treated as the same measure of identity. ‘Ethnicity’ boxes would sometimes only include racial categories, and ‘race’ boxes would dismiss a few identities altogether, relegating any missed categories as ‘other.’ In some of the worst cases, I’ve noticed the distinguishing of racial groups as ‘white’ vs. ‘non-white,’ deeming ‘white’ groups to be the majority and lumping the rest of the participants into a monolithic mess. 

It is important to consider the subfield of cultural psychiatry. Cultural psychiatry is a subfield of psychiatry that focuses on the impact of culture and ethnicity on mental health and illness. It recognizes that cultural factors can influence the presentation and course of psychiatric disorders, as well as the way people seek help and cope with their symptoms. Despite the importance of cultural factors, however, there is often little incentive to include racial and ethnic identity in psychology research studies. This is partly due to the historical legacy of racism and discrimination in science, which has led to a lack of diversity among researchers and a reluctance to address issues of race and ethnicity. Additionally, funding agencies may not prioritize studies that focus on cultural factors, leading to a lack of resources for researchers in this area. It is often up to people with lived experiences and cultural identities to prioritize the inclusion of these cultural factors and demographics in order to ensure the integrity of the results and interpretations. 

One significant challenge in psychological research is the confusion between ethnic and racial identities. Ethnic identity generally refers to a shared nationality, cultural traditions, or common cultural characteristics, such as language, music, or beliefs. Racial identity, on the other hand, is defined by shared physical traits like skin color or facial features. The inconsistent use of these identity categories in research limits our understanding of how behavioral phenomena may vary between different groups. There have been recent discussions regarding the difficulties many Latinos have had in discussing theit racial identity, especially given that Hispanic and Latino response options are recognized only as an ethnicity. Other cultural groups may also struggle in identifying themselves with the current racial identity choices on federal surveys. This is particularly salient for many people who identify as Asian, as this label does not adequately describe the various cultures or ethnicities across the region (i.e., lumping people from Eastern Asian and Southeast Asian into one category).  In particular, Americans of Middle Eastern and North African (MENA) heritage have been largely overlooked in research due to the lack of representation in key demographic surveys, such as the U.S. Census. As a result, there is a significant gap in the literature regarding the specific discrimination and ethnic trauma experienced by this population. And in the cases where      MENA groups are studied, they are often treated as a single, homogenous group, without considering the diverse cultural and historical factors that contribute to the transmission of trauma across generations, such as colonization, political unrest, and wars.

Cokley, in his paper on the critical issues of measurement of ethnic and racial identity (2007), notes the importance of separating ethnic identity from racial identity, as each category serves different purposes. In studies that evaluate individuals’ cultural beliefs, values and behaviors, ethnic identity should be prioritized. Likewise, if researchers are interested in examining the ways in which identities are formed in a racialized society, racial identity should be measured. Inconsistent and interchangeable use of these identity groups can create confusion in research studies, oftentimes erasing the identities people      most associate with. This can have harmful repercussions, especially when  results are used to define and characterize entire groups of people.

Once ethnic and racial identity are clearly defined in the context of the study, researchers can proceed to select an adequate instrument that can assess the racial-ethnic identities of the participants. Racial-ethnic identity is also incredibly complex to categorize, as it is an amalgamation of one’s beliefs, cultural practices, socialization, and individual differences. When these sample characteristics are boiled down to the minimum – oftentimes a single trait – racial and ethnic identity are reduced to      afterthoughts. In reality, multicultural practices should be integrated into research, especially when the results are being used to make sweeping generalizations to entire populations. 

Once assessments are chosen, a rationale should be provided as to why these specific tools were used in comparison to others in the field. This helps boost the reliability and generalizability of racial-ethnic identity measures.  Assigning, collecting, and quantifying the data should be more transparent in order to better understand the efforts of psychologists and researchers to diversify their samples to avoid biases. 

There exists a clear distinction in the approaches used to identify and manage psychological distress among racially and ethnically diverse populations. To begin, racism is defined as a system of institutional and individual prejudice directed against racial group(s) and their members, where power is maintained by the oppressor to institute discriminatory policies and actions (Neville, 2009). In the racial identity literature, researchers have developed several models for racial discrimination, racial stress, and race-based traumatic stress that specifically address structural and interpersonal forms of racism that may threaten someone’s physiological, emotional, and psychological well being (e.g. Carter, 2007; Jackson et al., 1996; Kubany et al., 2000; Clark et al., 1999; Slavin et al., 1991). In contrast, when evaluating ethnicity, researchers focus on acculturative stress to explain the cumulative stress/trauma associated with the clashing of values, practices, and languages (Bhattacharya & Schoppelrey, 2004; Gil et al., 1994; Berry, 1974; Torres, 2010). Acculturation refers to the assimilation of the dominant culture, which can lead to psychological, physical, and emotional distress in marginalized groups who are often told to adapt their religious, linguistic, and cultural practices in order to avoid harassment (Berry, 1974). It is important to note that we do not exist in a vacuum, and that our racial and ethnic backgrounds compound to form one social identity; however, this does not take away from the importance of noting the distinctions between the two constructs in order to better develop interventions for negative experiences that distinctly surround racism vs. ethnic/cultural discrimination. One final way that researchers can ensure that racial and ethnic identities are properly accounted for is by paying attention to the differences in ethnic identities across broader racial groups. For example, if a participant identifies as “White,” it is worth noting the discrepancies across people who may identify as “Middle Eastern,” “European,” or “Northern African.” All in all, it is imperative that researchers strive to provide options for people to adequately identify with their racial and ethnic group of choice. As of a few months ago, the Biden Administration came out with a proposition to introduce a new checkbox for “Middle Eastern or North African” in all federal government surveys by 2030. This would be the first step in standardizing the inclusion of an ethnicity box that adequately and appropriately captures the unique MENA cultural experiences. The hope is that this will have a ripple effect across all disciplines, eventually making its way to the psychology discipline, where the norm will be to accurately report on demographics. I envision myself, 10 years from now, phone in hand, with the ability to finally choose an option that resonates most with my cultural and ethnic identity.

Katrina Rbeiz is a graduate student in the clinical science PhD program at Vanderbilt University. She is passionate about increasing the representation of Middle Eastern and North African (MENA) populations in psychological research and clinical work, as well as developing culturally valid assessments and interventions that identify risk and resilience factors for ethnically diverse populations with serious mental illness (e.g., schizophrenia spectrum disorders). Find her on Twitter @ThirdCultureKat.

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