Author Note

Correspondence concerning this article should be addressed to: Sazan Meran, 301 Pyrene House, Clayponds Lane, Brentford, Middlesex, TW8 0GR. Email: [email protected]

Abstract

British Muslims habitually respond to the onset of mental ill-health by turning to their faith leaders. How Muslim faith leaders manage these encounters remains largely unexplored. In this study, 41 Muslim religious leaders in the UK completed vignette-based surveys depicting an individual meeting DSM-IV criteria for depression or schizophrenia. Participants were questioned regarding beliefs about etiology and treatment, counseling training and activity, and referral behavior; stigma levels were also measured. Muslim faith leaders were found to exhibit low stigma, provide substantial informal counseling, and routinely refer individuals to mainstream mental health services. They simultaneously embraced environmental, biological, and religious causes for mental illness. Muslim faith leaders emerge as potential allies in efforts to improve mental health outcomes for British Muslims, by challenging community stigma and collaborating with mental health professionals to deliver holistic care.

In 2005, the U.K. Department of Health published an action plan for delivering race equality in mental health care and found a significant need to provide culturally appropriate services to individuals from ethnic minorities, as well as address high levels of distrust of mental health professionals among these groups (Department of Health, 2005). With an estimated population of 2.7 million, British Muslims form the second largest religious group in the U.K. and are one of the most rapidly growing minority groups, with 1.2 million more people identifying as Muslim between 2001 and 2011, representing a jump from 3 to 5 percent of the overall population (Office for National Statistics [ONS], 2013). Muslims in the U.K. form a heterogeneous and ethnically diverse group, with 68 percent from a South Asian background, 10 percent reporting as Black (African/Caribbean or British), and 11 percent identifying as ‘Other Ethnic Group’ (ONS, 2013). British Muslims are among the worst affected by health inequalities, and have the highest reported rates of illness and disability of all minority groups (Hussain, 2009; Sheikh, 2007). In the current political climate, where Muslims are increasingly portrayed negatively (Ahmed & Matthes, 2017), the mental health of this group is under particular threat (Sheridan, 2006; Ali, Milstein, & Marzuk, 2005; Ali, Liu, & Humedian, 2004). A study of Muslims living in Britain, France, and Germany found that perceived Islamophobia predicted higher levels of psychological distress and perceived stress (Kunst, Sam, & Ulleberg, 2013), and evidence suggests that South Asian populations in the U.K. have a heightened risk of psychological morbidity (Fazil & Cochrane, 2003).Minority ethnic groups face barriers to accessing mental health services, due in part to mistrust of mental healthcare professionals and stigma within communities (Bowl, 2007; Williams, Turpin, & Hardy, 2006; Keating & Robertson, 2004; NIMHE, 2004). A survey of 152 members of a Pakistani Muslim community by mental health charity Rethink Mental Illness (2007) found a consistent lack of uptake of mental health services. There is evidence that South Asian Muslims in particular are less likely to access mental health services than all other groups (Sheikh & Furnham, 2000). Services may also lack knowledge or understanding in approaching these groups, and are therefore commonly viewed as irrelevant (Weatherhead & Daiches, 2010; Bhui & Morgan, 2007; Ali et al., 2004).

Muslims habitually turn to faith leaders at times of emotional and psychiatric difficulty (Dein, 2013; Al-Krenawi, Graham, Dean, & Eltaiba, 2004; McCabe & Priebe, 2004; Cinnirella & Loewenthal, 1999). Barn and Sidhu (2005) interviewed 54 Muslim Bangladeshi women who identified imams and traditional healers as their main source of support in terms of seeking healthcare. Similarly, Dein, Alexander, and Napier (2008) report that a sample of Bangladeshi Muslims in East London turned to imams and traditional faith healers before seeing medical professionals. Another survey of 111 Muslims found that a majority believed in supernatural causes of physical and mental illness (including jinn possession and black magic), and 54 percent believed treatment should be sought from both doctors and religious figures simultaneously (Khalifa, Hardie, Latif, Jamil, & Walker, 2011). In an observational study of 123 patients attending an Early Intervention Service for Psychosis, Singh and colleagues (2015) found black and Asian patients were more likely to pursue help from faith organizations, although this did not result in their delayed presentation to mental health services.

Imams: De Facto Mental Health Providers

The traditional role of an imam is to lead prayer, conduct religious ceremonies, deliver sermons, and provide spiritual and religious guidance (Haddad & Lummis, 1987). The imam plays a central role in the communal and spiritual life of Muslims and has a great deal of trust and respect placed in them (Siddiqui, 2004). Since Sunni Islam does not have a formalized clergy system, most mosques do not operate with standardized religious hierarchy (Maqsood, 2008; Boender, 1999), and it can be difficult to clearly identify the providers of support in an Islamic context. There are a broad range of religious teachers, spiritual guides, and scholars based in mosques, community centers, and educational establishments, any of whom may be approached by members of the Muslim community struggling with psychological difficulties (Pilkingon, Msetfi, & Watson, 2011). All of these are encompassed here in the category ‘Muslim faith leaders’. Faith leaders may perform Ruqya, an Islamic prayer modality that uses recitation of Quran verses or supplications of the Prophet Muhammad for healing (York, Perez-Chisti, Lewis, & Yucel, 2011).

Examining pastoral care provided within different faith groups, Leavey (2008) interviewed seven Muslim religious leaders who felt they were the first port of call for individuals in their community with psychiatric problems, more so than Christian and Jewish clergy. Across faiths, clergy are frequently front-line responders for congregants facing the onset of mental illness, and serve to facilitate these individuals’ access to a broader network of mental health services (Larson et al., 1988; Piedmont, 1968). This role is particularly significant in minority ethnic communities, given the context of high disparities in access to healthcare (Ali et al., 2005; Young, Griffith, & Williams, 2003).

Despite the apparently central role played by Muslim faith leaders in the provision of support to individuals with psychological difficulties, highlighted by patients and religious leaders alike, there has been limited exploration of their role. What studies do exist in a U.K. context are qualitative in nature, utilizing a very small sample. For instance, Rashid, Copello, and Birchwood (2012) examined the views of eight Muslim faith leaders, including four imams, two shaykhs, one mullah, and one female religious teacher, on psychosis and substance misuse. The religious leadership simultaneously held medical and religious beliefs about the causes of mental illness, deploying both within the same narrative and finding no conflict between the two. Participants at times spoke about schizophrenia as having a biomedical etiology, requiring psychiatric intervention, and at other times stated they believed psychotic symptoms were caused by jinn possession. Similarly, Ally and Laher (2007) interviewed six Muslim faith healers in South Africa about the perceived causes of mental illness; this was sometimes held to have environmental or biological causes (stress, trauma, or chemical imbalances in the brain), although spiritual problems could present as mental ill-health. The healers claimed the ability to distinguish between spiritual illness with a supernatural cause, such as black magic or jinn, and mental illness. In another qualitative UK-based study, Watts, Murray, and Pilkington (2014) performed a phenomenological analysis of the experiences of six imams, all of whom saw providing counseling and pastoral care as a core part of their role and acted in a manner analogous to central diagnostic practitioners: Directing those with medical ailments to doctors, and those with jinn difficulties to a spiritual expert. Imams reflected that while they made referrals to medical services, a reciprocal relationship did not exist.

A small number of quantitative studies have been conducted in the U.S. on the role played by imams in the mental health of Muslims. Ali and colleagues (2005) surveyed 62 imams across the U.S., and found that 95 percent spent a significant amount of time each week counseling congregants with psychiatric difficulties. However, imams were less likely than clergy from other faith groups to have formal counseling training. In a second study, Ali and Milstein (2012) utilized a vignette-based survey depicting an individual exhibiting symptoms of depression to assess imams’ beliefs about the etiology of mental illness and helpful interventions, as well as their referral practices and counseling experience. Their principal finding was that imams recognized the severity of serious mental illness and the necessity of some type of intervention in order to attain recovery. Imams were most willing to refer congregants to mental health professionals while continuing to provide counseling themselves. However, although imams recognized the validity of mental health interventions alongside religious interventions, actual referrals to mental health professionals were low. Abu-Ras, Gheith, and Cournos (2008) conducted a cross-sectional survey of 22 imams and 102 Muslim worshippers in 22 mosques in New York City, and found that members of the Muslim community most frequently sought support for mental health issues from imams. The majority of imams had not received any formal training in Western psychotherapy interventions, yet they nevertheless played a central role in promoting congregants’ mental wellbeing through unstructured psychotherapy interventions.

Perceptions of Illness Severity: Depression vs Schizophrenia

While Ali and Milstein (2012) used a depression vignette in their survey of US-based imams, this study sought responses of Muslim faith leaders to vignettes of individuals with symptoms of both depression and schizophrenia. Evidence suggests that both the general public and religious groups have differing perceptions of individuals suffering from schizophrenia and depression, viewing those with schizophrenia as more dangerous (Pescosolido et al., 2010). This remains true even for individuals reporting familiarity with schizophrenia (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). In a study including several religious groups in Britain, Cinnirella and Loewenthal (1999) found that participants in all groups felt schizophrenia was more serious and more likely to have an organic cause than depression. In contrast, depression was more likely to be viewed as resulting from a religious failing on the part of the patient.

Beliefs about Etiology and Treatment

Research shows that beliefs about what causes psychiatric illness affect the likelihood of a person accessing support from mental health services (Hill & Bale, 1980). Explanatory models – the set of assumptions held about the causes of ill-health – are profoundly different across cultures and influence the mode of help sought by an individual when unwell (Lynch & Medin, 2006). Consequently, this study asks whether Muslim faith leaders attribute mental illness to environmental, biological, or religious causes, and how these beliefs about etiology impact beliefs about appropriate treatment responses, as well as referral practices to mainstream mental health services.

Mental Health Stigma

Several ethnic and cultural minority groups have been found to stigmatize those with mental health difficulties to different degrees (Rao, Feinglass, & Corrigan, 2007), and high levels of mental health stigma have been specifically found within Muslim communities (Cifti, Jones, & Corrigan, 2012; Tabassum, Macaskill, & Ahmad, 2000; Cinnirella & Loewenthal, 1999). However, Muslim faith leaders are likely to have considerably more contact with congregants in mental distress or with mental health problems and the degree of social distance they desire is unknown. It is plausible that they hold very different perceptions of mental illness than British Muslims in general, and have less stigmatized views. This is because successive studies have found that individuals with greater experience of mental illness are less prone to endorse stereotypes of dangerousness or desire social distance (Angermayer, Matschinger, & Corrigan, 2004; Corrigan, Edwards, Green, Diwan, & Penn, 2001; Penn et al., 1994).

Aims and Hypotheses

Muslim faith leaders in the U.K. are seemingly playing significant roles as front-line responders to individuals experiencing psychological difficulties; This study aims to broaden our understanding of their beliefs and behaviors when providing this mental health support. Due to evidence that British Muslims facing mental illness routinely turn to their religious figures, it is hypothesized that Muslim faith leaders are providing substantial informal counseling in British Muslim communities. However, given findings of limited formal counseling training among imams in the U.S. (Ali et al., 2005), similarly low levels are anticipated here. Furthermore, with evidence of an inverse relationship between contact and stigma, Muslim faith leaders reporting greater familiarity with mental illness are hypothesized to exhibit less stigma. Nevertheless, based on prior vignette studies, it is expected that participants will desire greater social distance from those with schizophrenia, perceiving the patient to be more dangerous and the illness more severe than depression. Finally, it is hypothesized that Muslim faith leaders attributing mental illness to spiritual causes will be more likely to view religious interventions as helpful, and less inclined to direct individuals to seek medical help.

Method

Results

As several of the variables are categorical, and those using Likert scales did not approximate normal distributions, parametric statistical analysis was precluded. As a result, non-parametric statistics were used. Spearman’s Rho correlation was used to test associations within the data. Differences between the depression and schizophrenia vignette conditions were analysed using a Mann Whitney test.

Discussion

This study is the first attempt to describe and quantify UK-based Muslim faith leaders’ responses to individuals presenting to them with symptoms of mental illness. It has confirmed that these religious leaders are seen by many British Muslims as valid providers of treatment for psychological difficulties, revealed the extent of the informal counseling they deliver, and indicated relatively low mental health stigma in this group.

It was hypothesized that due to Muslim faith leaders’ frequent contact with those with psychological difficulties, borne of the substantial counseling role they play in the community, they would have high familiarity with and therefore exhibit relatively lower stigmatizing attitudes toward mentally ill individuals. This hypothesis was in line with evidence indicating that contact increases familiarity, which is linked with reduced stigma in turn (Angermeyer et al., 2004; Corrigan et al., 2001; Penn et al., 1994).

While no association was found between familiarity and stigma in this study, Muslim faith leaders did express comparatively less stigma toward individuals with mental illness than has been found in the broader Muslim community. On measures of social distance, nearly all participants were willing to live next door to or spend an evening socializing with the individuals depicted in the vignettes, or to have them as a friend. Over two-thirds were willing to work closely with Ahmad or Zaid on a job, while over half were willing to have their children marry someone like them. These findings are strikingly different from those reported by Tabassum and colleagues (2000) in their study of 45 British Pakistani Muslims. None in that sample would consider marriage with an individual with mental illness, while less than a quarter would consider a close relationship, and less than half would be prepared to socialize with such a person. In addition, numerous descriptive studies have highlighted that mental health stigma within Muslim communities constitutes a particularly troublesome barrier to accessing services, more so than in other religious groups (Leavey, 2008; Bradby et al., 2007; Gilbert, Gilbert, & Sanghera, 2004).

It is unclear why no correlation was found between familiarity and stigma levels in this study given the established link between these two factors in the literature. Perhaps the sample size was too small to detect a relationship, or there may be a third, unknown factor responsible for lower desire for social distance among Muslim faith leaders. This is a worthwhile area for further investigation given the near absence of literature exploring stigma levels in this group.

While Muslim faith leaders scored relatively better on measures of social distance, over two-thirds believed it likely that the individual depicted with schizophrenia was likely to commit acts of violence toward others. This aligns with successive studies illustrating that schizophrenia patients are perceived as dangerous (Pescosolido et al., 2010; Crisp, Gelder, Goddard, & Meltzer, 2005). Although those with schizophrenia are indeed at an elevated risk of perpetrating acts of violence (Wallace, Mullen, & Burgess, 2004), public fears substantially inflate this risk (Crisp et al., 2000; Steadman et al., 1998). Thus, there remains work to do in adjusting misconceptions of those with schizophrenia among Muslim faith leaders.

Why do stigma levels among Muslim faith leaders matter? As hypothesized, these leaders play a considerable role in responding to the needs of individuals in their communities with mental health problems. Nearly two-thirds of participants reported spending time each week counseling those with psychological difficulties, with over half reporting spending between one to five hours weekly, and the remainder spending between 6 and over 20 hours per week. This quantifies findings in earlier qualitative UK-based studies in which imams stated that providing help to community members with mental illness was central to their role (Watts et al., 2014; Leavey, 2008), and British Muslims expressed a strong tendency to first approach religious leaders when experiencing psychological distress (Dein, 2013; Barn & Sidhu, 2005; McCabe & Priebe, 2004). Consequently, Muslim faith leaders’ attitudes to mental illness set the context in which many individuals in their community react to the onset of psychiatric ill-health. Such attitudes can translate into acceptance or rejection; prompt or delayed help-seeking; empathy or fear.

So why have the attitudes of Muslim religious leaders not already translated into reduced stigma toward the mentally ill in the Muslim community? While imams clearly play a significant role in providing informal counseling and signposting to mental health services, the first intervention study challenging mental health stigma among Muslims in the U.K. supported the power of social contact with an individual with lived experience of mental illness to reduce mental health stigma in this group (Hankir et al., 2017). This suggests that partnerships between Muslim faith leaders, experts by lived experience and mainstream mental health professionals may hold the key to reducing mental health stigma in British Muslim communities.

Muslim faith leaders are also crucial allies in any attempts increase trust in mental health professionals. The results revealed that participants frequently directed individuals with psychological difficulties to seek help from mainstream healthcare providers, with the vast majority making such referrals to other agencies and services in the past year. Nearly two-thirds had directed individuals to see their GP and over half had recommended consulting a psychiatrist or psychologist. This represents higher referral rates than reported in a comparative study of US-based imams, where less than half had referred congregants to a primary care physician, or a psychiatrist or psychologist (Ali & Milstein, 2012). In line with the study’s hypotheses, Muslim faith leaders who attributed mental illness to spiritual causes were more likely to view religious interventions (in the form of seeing a raaqi) as helpful. However, this was not associated with an eschewing of biological or environmental causes, the rejection of medical interventions, or, contrary our hypothesis, a reduced tendency to refer congregants to mainstream mental health providers.

Muslim faith leaders appear to be actively encouraging British Muslim communities to overcome their aversion to mental health services. Given the absence of formal referral routes between these faith leaders and health services, it is not known whether individuals do in fact act on these recommendations, highlighting another important avenue for future research. However, evidence of low uptake of services among British Muslims (Rethink, 2007; Williams et al., 2006), perhaps demonstrates that even the recommendations of highly respected religious figures struggle to overcome the stigma associated with utilizing formal mental health support, or the belief that mental health services are irrelevant (Weatherhead & Daiches, 2010; Sheikh & Gatrad, 2009). Hence, tackling stigma alongside delivering religiously literate mental healthcare may hold the key to positively engaging British Muslims with mental health services.

Mental health professionals should consider Muslim faith leaders an invaluable resource in any effort to provide effective care to British Muslim patients. Broadly, Muslim faith leaders can educate mental health professionals about the importance of religion to an individual’s healing and recovery. In turn, health professionals can teach Muslim faith leaders to recognize and understand mental illness from a medical viewpoint. However, the practicalities of collaborative working when an individual wants to pursue both an Islamic and medical approach to receiving mental health support require greater formulation: In what instances do these approaches positively reinforce one another, when can they simply co-exist, and when is there irresolvable incompatibility? A principal area of negotiation will concern beliefs regarding the etiology of mental illness.

Our findings reveal that Muslim faith leaders most frequently ascribed mental illness to environmental reasons, followed by biological and then religious causes. However, they often embraced all three concurrently. This apparent syncretism between seemingly conflicting explanatory frameworks of mental illness has been evidenced in earlier studies of both Muslim lay persons and religious figures (Dein, 2013; Rashid et al., 2012; Khalifa et al. 2011). Muslim faith leaders seem open to a wide range of possible etiologies and so may variously suggest medical, psychological/emotional, and spiritual sources of support for the same individual. This may explain why the belief in spiritual causes did not translate to a rejection of medical interventions, as had been hypothesized.

Can mental health professionals in turn make room for religion and spirituality? Research shows that mental health patients are strongly averse to talking about their religious beliefs and behaviors for fear of facing cultural insensitivity, or even being branded deluded and hospitalized involuntarily (Dein, 2013; De Sousa, 2007). This is despite research indicating that respect for and understanding of a person’s religious beliefs is essential in developing meaningful therapeutic relationships (Weatherhead & Daiches, 2010). Such respect and understanding may be realized through the proposed partnership between mental health professionals and Muslim faith leaders. A tendency for psychiatrists to resist working with faith-based organizations has been noted (Durà-Vilà, Hagger, Dein, & Leavey, 2011), and it is true that the resolution of conflicting beliefs and treatment modalities may be problematic (Leavey, 2010). While the case cannot be made here that such antagonisms are surmountable, the implementation of such collaborations may improve the mental health care of a marginalized and vulnerable, but rapidly growing minority community in the U.K. One promising example is Mir and colleagues’ (2015) incorporation of Islamic teachings in an adapted behavioral activation intervention for depression, which was found to be feasible to implement in practice, and acceptable to most patients, therapists, and referral agencies.

Enhancing the mental health training of Muslim faith leaders may aid in the development of these working relationships. It was predicted that participants would have low levels of formal counseling training, as was found in a sample of American imams (Ali et al., 2005). The results suggest that while levels were not low, more – and perhaps better quality – training is required. Over two thirds had received some form of training in counseling or mental illness. Despite this, a majority did not believe their training was adequate to recognize mental illness. In addition, while most Muslim faith leaders surveyed were able to recognize the severity of the mental illnesses depicted in the vignettes, over a third believed Ahmad’s depression was likely to resolve spontaneously without intervention. Significantly, only six respondents had Clinical Pastoral Training. Improving uptake of this training among Muslim faith leaders may facilitate working partnerships with mental health professionals, since it provides a way to approach mental healthcare as part of a multidisciplinary team (Vandecreek & Lucas, 2001). Improved mental health training is also important since imams are in a unique position to help boost mental health literacy among British Muslims, and to aid in the recognition, management, or prevention of mental illnesses (Jorm et al., 1997).

The results of this study should be interpreted within the context of several limitations. The sample size used here is relatively small, which is an important limitation in a group as diverse as British Muslims. While the vignettes used were an attempt to replicate the types of encounters Muslim faith leaders may experience day-to-day, as well as provide a vivid depiction of someone with mental illness, they cannot truly mimic or evoke real-life responses, possibly compromising the ecological validity of our findings. Additionally, social desirability bias may have led participants to report more positive attitudes toward those with mental illness, or be less inclined to admit to beliefs in spiritual causes and remedies. This tendency to respond in a manner deemed socially acceptable may be a particular problem in a community currently under heavy and unwelcome scrutiny (Chakraborti, 2013; Awan, 2012, Nickels, Thomas, Hickman, & Silvestri, 2012), and highlights the importance of fostering trust when researching British Muslims.

This study represents an important step in building a picture of the role played by Muslim faith leaders in responding to the mental health needs of their communities. Further research is vital given the dearth of empirical research on this topic in the U.K., and some possible future directions have already been noted. Given the rich potential for partnership between Muslim faith leaders and mental health professionals, there is a need to develop, trial, and evaluate collaborative efforts. In addition, it appears that Muslim faith leaders believe it possible to distinguish between mental and spiritual problems, but more needs to be understood about how this diagnostic discrimination is made, and what consequences there are for the individual in need of support. Finally, it would be interesting to investigate the satisfaction levels of British Muslims who have turned to faith leaders for mental health support, to better understand their expectations when approaching religious figures ,and to determine whether they felt their needs had been adequately met.

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