Negative attitudes toward mental health services and providers

Past research has indicated the presence of negative attitudes in the Muslim population toward mental health services and providers (Ciftci et al., 2012). This may present barriers to seeking mental health care services. Many Muslims approach Western psychology with doubts regarding its congruence with Islamic perspectives on mental health or the Islamic way of life (Rassool, 2015). When considering religious, cultural, historical, and social contexts, especially of the immigrant Muslim community, it is apparent that Western mental health settings may not be favorable for Muslim immigrant clients (Amri & Bemak, 2012). Take, for example, how some religious beliefs and cultural norms that prescribe gender roles and sets limitations for intergender interactions would impact finding support; pairing a female client with a male counselor would be heavily looked down upon (Amri & Bemak, 2012; Walpole, McMillan, House, Cottrell, & Mir, 2013). Furthermore, because of the collectivist nature of the Muslim community, many Muslims may be unfamiliar and unwilling to draw attention to the self in a therapeutic setting because mental illness is seen as a “private family matter” (Ciftci et al., 2012; Walpole et al., 2013); partially for this reason, it is more socially acceptable to seek help from within the family or community as this approach protects the family’s social status (Amri & Bemak, 2012). Muslims may also hesitate to disclose religious conflicts, questions, and doubts related to matters of faith and God, among others, for fear that is morally wrong to do so and that it might incite negative appraisals or stigmatizing retort (Abu-Raiya, Exline, Pargament, & Agbaria, 2015). For immigrants and minorities, cultural mistrust of mental health counselors is one of the longstanding barriers to accessing mental health services (Amri & Bemak, 2012). The reasons for this include past experiences of racism, discrimination, and social exclusion that can be traced as far back to the tense post 9/11 socio-political climate which has negatively influenced help-seeking behaviors (Amri & Bemak, 2012). In addition, this mistrust is compounded by the fear that non-Muslim American counselors do not have the background needed to understand the cultural and religious contexts in which Muslims live, and for this reason they may suggest actions or lead the individual in a direction that may conflict with their values and belief systems (Amri & Bemak, 2012; Rassool, 2015).

Cultural beliefs associated with the cause of mental disorders

Studies show that for the expectations of both healthcare providers and their patients to be met, they must share similar conceptualization of disease and cure (Padela, Killawi, Forman, DeMonner, & Heisler, 2012). Therefore, for patient populations whose religious and cultural beliefs inform expectations of healthcare providers and serve as alternative philosophical frameworks for articulating the meaning of health and appropriate help-seeking behaviors, the formal healthcare setting may be unwelcoming (Padela et al., 2012; Martin, 2015; Rassool, 2015). This frame of help-seeking attitudes and behaviors may also explain the underutilization of mental health services among Muslims (Rassool, 2015). The Islamic perspective on mental health significantly contrasts with the secular etiology of mental health (Rassool, 2015). This is particularly important because although the Muslim community is ethnically, racially and socioeconomically diverse, it is bound together by religious worldviews that cut across social lines to inform how its members appraise distress, seek help and interact with the healthcare system (Padel & Curlin, 2012; Padela et al., 2012). Nevertheless, the diversity within this population means that for clinicians looking to understand beliefs related to the causes of mental illness, they must be aware the difference between culture and religion.

Some Muslims believe that depression occurs due to lack of faith; individuals or families with this opinion are less likely to acknowledge symptoms or seek professional psychological help due to the stigma (Amri & Bemak, 2012; Walpole et al., 2013). Consequently, such Muslims are more likely to use alternative informal resources that are more socially acceptable and within the frame of their beliefs (Ciftci et al., 2012; Haque & Keshavarzi, 2014). These alternative informal resources can be imams or local sheikhs, religious figures seen as indirect Divine authorities that are equipped to provide a variety of spiritual and non-spiritual services (Ciftci et al., 2012; Padela, Killawi, Heisler, DeMonner, & Fetters, 2011). Religious leaders play multiple overlapping roles, and imams have diverse qualifications and expertise owing to the absence of a formalized, uniform clergy system (Padela et al., 2011). Studies show that imams play an influential role in how families and communities view and respond to illness (Ciftci et al., 2012). In addition, they are also trusted figures and providing counseling to their congregants, adjudicating ethnical challenges in matters related medical care, and promoting healthy mental wellbeing (Ciftci et al., 2012; Padela et al., 2011). Muslims may also use a range of religiously endorsed coping strategies and beliefs (Padela et al., 2011; Walpole et al., 2013), alongside orthodox psychiatric or similar help (Walpole et al., 2013), without disclosing such information to mental health professionals for fear of being misunderstood (Samari, 2016).

It is not uncommon for Muslims to attribute depression to supernatural forces at work, and this includes possessions by demons known as jinns, ramifications for past sins, being cursed by the evil eye (al-ayn), black magic (seher; Amri & Bemak, 2012; Haque & Keshavarzi, 2014; Rassool, 2015), and witchcraft (jadoo; Walpole et al., 2013). Another belief common among Muslims is that mental illness is caused by Divine chastisement or a test on the forbearance of the individual which leads to increased tolerance of mental illness, as the individual is subjecting themselves to God’s will (Amir & Bemak, 2012; Walpole et al., 2013). These beliefs about the cause of mental illness may influence patterns of help seeking and response to treatment (Amri & Bemak, 2012; Ciftci et al., 2012).

Shame and stigma attached to mental health problems and services

While studies have identified numerous factors contributing to mental health disparities, stigma is perhaps one of the most significant and constant challenges to accessing mental health services (Amri & Bemak, 2012; Ciftci et al., 2012). The U.S. Department of Health and Human Services has reported that social stigma is probably the single largest hidden contributor to the burdens of mental illness (USDHHS, 2001). Studies show that in many cultures mental illness and treatment is heavily stigmatized; in the same manner, psychopathology is heavily stigmatized within the immigrant Muslim community (Amri & Bemak, 2012). Stigma not only discourages people from seeking help for psychological distress (Amri & Bemak, 2012), it is itself a source of psychological distress (Hankir, Carrick, & Zaman, 2017).

Research has indicated that some Muslims disapprove of mental disorders and consider it a shameful action to seek mental health services and use psychiatric medications which may lead affected individuals to hide their mental health issues; this causes problems with interpersonal relationships and integration within the community (Rassool, 2015). This negative attitude toward seeking professional help may also be due to feelings associated with reputation among family, tribe, and society, which bear weight across a diversity of cultures (Ciftci et al., 2012).

Unfamiliarity with the existence of formal services

The reluctance of some Muslims to seek formal help has also been linked to their lack of familiarity with the formal health care system (Lai & Surood, 2013). A study examining the experiences of immigrant patients in mental health services suggests that unfamiliarity with how health care services operate in the host country is among the issues specific to immigrant groups (Sandhu et al., 2013). In other words, unfamiliarity with the health care system, or how health care services function is a major challenge to building therapist-patient alliance (Sandhu et al., 2013). Studies show that South Asians are more likely to deny having psychological problems because they’ve been socialized to not disclose problems to people outside the family for fear of negative response, and for this reason they are less confident in seeking help from mental health professionals (Lai & Surood, 2013). Considering these limitations, it is not surprising that some Muslims choose informal methods of treatment, closely related to cultural values and Islamic beliefs, over formal mental health services. However, with the growing body of work on religion and spirituality in clinical practice, alongside the successful application to clinical practice (Haque et al., 2016), demands for effective treatment practices are likely to increase religiously observant Muslims seeking culturally competent professional help.

Research Hypotheses

Controlling for length of stay in the U.S., gender, age, education, and socioeconomic variables, the following hypotheses were proposed:

1. Muslim Americans with more culturally traditional beliefs about mental health will report less favorable attitudes toward formal mental health services;
2. Those who perceive higher levels of shame associated with the seeking formal mental health services will report less favorable attitudes toward formal mental health services;
3. Those with less knowledge about and familiarity with mental health problems, services, and providers will report less favorable attitudes toward formal mental health services; and
4. Muslim Americans who choose informal resources as their most preferred help resources will report less favorable attitudes toward formal mental health services than those who choose formal resources as their most preferred help resource.

Participants and the Selection Process

This research study was approved by Midwestern University Institutional Review Board (IRB) prior to collection of data.

The participants were recruited at an annual convention using non-random, convenience sampling method. Moreover, about one-third of the participants were recruited online through social media using similar sampling methods. The study sample was restricted to individuals aged 18 years old or older, identify themselves as Muslims, and currently live in the United States.

Measures

The questionnaire in this study was previously used in a study on Arab American Muslims living in Columbus, Ohio (Aloud & Rathur, 2009). Written permission was obtained from the primary author before conducting this study.

The 58-question survey is divided into four sections:

1. Attitudes toward seeking formal mental health services. This portion was developed and adapted by Aloud from the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPH; Fischer and Turner, 1970). The newly constructed instrument was called The Attitude Toward Seeking Formal Mental Health Services (ATSFMHS) and was constructed based on a Likert-type scale (1 = Strongly Agree, 2 = Agree, 3 = Disagree, and 4 = Strongly Disagree).
2. Cultural beliefs about mental health problems. This section assessed the influence of cultural, traditional, and Islamic beliefs regarding the causes and treatment of mental health problems among Muslims. The instrument consists of eleven Likert-type items (0 = False, 1 = Probably False, 2 = Probably True, and 3 = True) and was developed for the specific use previous (Aloud & Rathur, 2009).
3. Knowledge and familiarity with formal mental health services. This section was developed by Aloud and Rathur (2009) to specifically examine the extent to which Muslims are familiar with the types of mental health problems (e.g., depression, anxiety, schizophrenia, etc.). This section also examines how familiar the respondent is with the role of mental health professionals in various settings, along with the location and means of contacting local formal mental health providers, and common formal mental health interventions.
4. Demographic information. The 12 questions in this section assess the basic demographic information of the respondent (e.g., age, gender, length of stay in the U.S.), and their history of using mental health services.

Demographic Variables

Descriptive analyses were conducted on all demographic and background variables obtained from the 166 participants who responded to the questionnaire. A summary is provided in the table below (Table 1).

When taking demographic variables into consideration, some interesting findings were observed in the collected data. With regards to age, there was a statistically significant (p<.01) inverse relationship observed. As the age of participant increased, their adherence to cultural beliefs decreased. This is a counterintuitive finding against previous research by Al-Adawi and colleagues which reported that younger individuals tend to be less accepting of cultural and traditional explanations of mental health problems than older individuals (2002). With regards to the level of education, it was observed that as the level of education increased, adherence to cultural beliefs decreased. This inverse correlation was also statistically significant (p<.05).

The sample's primary characteristics (i.e., gender, age, education level, socioeconomic status, etc.) were analyzed by using descriptive statistics, including frequency distributions, measures of central tendency, and measures of variability. Dummy-coding method was used to add the categorical variable (help-seeking preferences) into the regression analysis. The original six help resource categories were re-coded from formal to informal sources of help where the mental health professional was the most formal source, followed by a medical doctor, etc.

Summary of Responses to the Questionnaire

Tables 2 summarizes the means, standard deviations, and the ranges of the responses. Muslim Americans endorsed somewhat favorable attitudes (mean=2.77, SD=0.408) toward the seeking and using formal mental health services. Participants reported somewhat decreased levels of stigma and shame (mean=2.08, SD=0.528) associated with seeking help for mental health problems, somewhat lower levels of internalized cultural beliefs about mental health problems (mean=2.25, SD=.470), somewhat increased amount of knowledge and familiarity of mental health problems, formal services, and professional providers (mean=2.55, SD=0.755). Finally, participants reported to be more likely to seek help from a formal mental health professional than an informal source (mean=4.00, SD=.823).

A bivariate correlation analysis was conducted to check for correlations between variables and assess the variation in the data. As Table 3 suggests, attitudes of Muslim Americans were statistically significant when compared with the four independent variables. Attitudes were positively correlated with societal stigma, negatively correlated with cultural beliefs, positively correlated with knowledge and familiarity, and positively correlated with help-seeking behaviors of Muslim Americans. In other words, Muslim Americans who perceive higher levels of societal stigma, have lower cultural beliefs, are more knowledgeable and familiar with mental health issues, and will seek formal mental health services have favorable attitudes toward seeking and using mental health services. Another statistically significant result was the negative correlation between cultural beliefs and knowledge and familiarity. In other words, Muslim Americans who have stronger cultural beliefs will have low knowledge and familiarity with mental health issues. Cultural beliefs appear to have the strongest influence on attitudes, followed by societal stigma, knowledge and familiarity, and help-seeking preferences.

Hierarchical Multiple Regression Analysis

Hierarchical multiple regression analysis addressed the question: “Among Muslim Americans, which of the following factors best explains individual attitudes toward seeking and using of formal mental health services?” Four independent variables were selected and their effects on help-seeking attitudes toward formal mental health services was tested: a) cultural beliefs about mental health problems; b) perceived societal stigma; c) knowledge and familiarity with formal mental health services; and d) help-seeking preferences. Demographic characteristics (gender, age, education, socioeconomic status, and length stay in the U.S) were treated as controlled variables in the regression analysis.

The data was tested to check for the violation of regression analysis assumptions of linearity, homoscedasticity, and normality. No violations were observed in the data.