Community consultation

The first Hand of Hope therapeutic group intervention was coproduced with a group of 10 British Arabic-speaking, MENA-origin, Muslim first- and second-generation women, affected by the Grenfell Tower fire. All reported witnessing the fire. Eight women were bereaved and had lost multiple close friends in the fire; six women described symptoms consistent with PTSD, and three women were permanently displaced in connection with the Grenfell Tower fire. Prior to establishing the group, only two women were accessing therapy via NHS GHWS, but none of the group members’ children nor the other eight women were engaging with mental health services or accessing therapy. For the first Hand of Hope therapeutic group intervention, the group requested to connect with other bereaved women, cook and share a meal together, focus on their religion, and access faith-informed culturally appropriate therapeutic support. Some of the women knew each other from the community.

The Hand of Hope therapeutic group intervention consisted of eight once-weekly two-hour sessions and ran from April to June 2018, 10 months after the Grenfell Tower fire. The aim was engagement, to provide culturally appropriate faith-informed therapeutic support, reduce the shame and stigma attached to mental health and therapy, provide psychoeducation, strengthen and activate social support networks, support stabilization, and improve access to services for the service users and their children. The group sessions focused on the cultural healing practices/collective cultural coping strategies: group cooking and communal gatherings over food (Abi-Hashem, 2006; Zarifi, 2015), and ‘hikaya’ oral storytelling (Atallah, 2017; see Table 2.).

Outline of the Hand of Hope therapeutic group intervention one

In this section, we outline the first Hand of Hope therapeutic group intervention. “Engagement and Consultation,” the first two sessions, focused on establishing relationships and a group contract, building trust by exploring the religious concept of amanah (trust), facilitating group bonding and engagement via group activities and icebreakers, identifying the group’s needs and coproduction. To manage interpersonal difficulties mediation was offered to group members who had historic personal difficulties with each other.

Session 3, “Coping with Loss”, involved exploring ways of coping with loss informed by their faith and supporting bereaved friends and family, exploring their views on bereavement, loss/grief-related emotions, and the impact of suppressing emotions. The aim was to provide psychoeducation on bereavement and strengthen positive coping.

Session 4, “Managing and Making Sense of Traumatic Experiences/Responses,” focused on supporting clients to recognize and manage trauma responses/symptoms by providing psychoeducation on trauma responses, reducing shame and stigma by normalizing trauma responses, promoting stabilization by exploring self-soothing techniques, and trauma and anxiety symptom management, including faith-informed grounding techniques like listening to Qur’an and dhikr (remembrance of God).

Session 5, “Exploring Impact of Bereavement and Grief,” focused on exploring their perspectives on grieving/mourning including Islamic perspectives, psychoeducation on grief/bereavement responses to increase awareness of the impact of bereavement and reduce shame and stigma, and remembering their loved ones and sharing memories of them. To support the processing of loss and distress, we normalized grief responses and permissibility to cry using Qur’anic stories of the prophets to promote balanced thinking regarding negative religious coping and support cognitive processing regarding beliefs about crying and expressing distress. We reflected on the religious concept of sabr (perseverance) and Qur’anic verses and Hadith group members found meaningful to aid positive coping.

Session 6, “Exploring Experiences of the Grenfell Fire Tragedy,” involved exploring the emotional impact of their trauma and loss and processing trauma in a culturally familiar way. Some group members chose to narrate their experiences of the fire in sequential order and were supported by the group. We explored religious forms of coping and religious conceptualizations of their experience.

Session 7, “Talking about Loss with Others and Mental Health Awareness,” explored what mental health and therapy is and associations made to increase mental health awareness and challenge stigma associated with mental health and seeking therapy. In this session, we explored the group ending, remembered the deceased, and normalized difficult feeling states. We also addressed their concerns that they would be burdening their friends if they opened up about their difficulties, by modelling difficult conversations, promoting social support, and exploring how group members would like to be supported by others.

Session 8, “Group Ending/Marking Eid,” involved exploring experiences of Eid without their loved ones, reflecting on the group’s journey, and supporting their request to mark their first Eid al-Fitr since the fire as a group.

Participants

All 10 group members were verbally invited to take part in the service evaluation. Seven participants that took part in the service evaluation were British first- and second-generation MENA-origin Muslim bereaved women, ages ranging 36 to 83, affected by the Grenfell Tower fire. Three group members who were unable to take part in the focus group interview due to other commitments were contacted individually to provide verbal feedback as part of the service evaluation; their feedback is included.

Procedure

Prior to the service evaluation, NHS approval was obtained. All participants were verbally provided with a description of what the service evaluation involved, the purpose, and the voluntary nature of their participation. Verbal consent was gained by the participants before taking part in the service evaluation. Participants were aware that they could withdraw from the evaluation, refrain from answering any questions, that the data would be anonymized with no identifying details, and that their participation would not negatively affect current or future services offered.

A mixed-methods service evaluation of the Hand of Hope intervention was conducted by the first three authors. A semi-structured focus group was held in June 2018 with seven group members in Arabic and English, which included the group members anonymously rating quantitative questions on a Likert scale. The focus group was audio-recorded with the participants’ consent and transcribed verbatim in English. Examples of focus group questions included: “how have you found the group?” and “how did you find the cooking activities?” The questionnaire was read aloud and participants completed a paper copy anonymously, which was deposited in a box. The audio recording of the focus group was translated by the third author, and transcribed verbatim in English by the first author. The data regarding referrals and access to therapy/services before and after the group was monitored, overseen, and collected by the first three authors and checked on each service’s databases; participants were also individually asked if they were accessing any services/therapy prior to inclusion in the group.

Data analysis

A thematic analysis following Braun and Clarke’s (2006) guidelines was conducted on the English translation of the focus group interview by the first author and was cross-referenced by the second author. The transcript was analytically coded on a line by line basis to generate initial codes and to identify possible themes. There was an emphasis on identifying distinct themes which related to the barriers reported in accessing therapy/mental health services, service user experience of the intervention, and evaluating the impact and outcomes of the intervention. The potential themes were reviewed to ensure that it captured the data contained in the transcript, and some subthemes were collapsed and renamed to better represent the data. Data extracts are provided in the findings section to allow the reader to evaluate whether the theme is representative of the data. The anonymized quantitative ratings were averaged using a calculator.

Barriers to accessing mental health services and therapy

The findings regarding the theme of barriers to accessing mental health services and therapy will be discussed first, followed by the (theme) outcomes of the first Hand of Hope group evaluation. To avoid repetition, the data extracts on the barriers presented are in response to the question, “Have you encountered any difficulties or barriers to accessing therapy in relation to Grenfell?”.

Shame and stigma attached to mental health and seeking therapy

Consistent with the literature, all reported that the shame and stigma attached to mental health and seeking therapy was a major barrier to accessing mental health services (e.g., Alhomaizi et al., 2017; Arday, 2018; Hamid & Furnham, 2013; Memon et al., 2016; Rayan & Jaradat, 2016; Woods-Giscombe et al., 2016). Some participants reported fears of being ostracized if they accessed support. All referred to mental health as meaning someone is “mad,” and some expressed that therapy is for “crazy” or “psycho” people. It is possible that their understanding of mental health and mental health care is informed by their experiences in their countries of origin. Mental health typically has negative connotations and is popularly associated with people experiencing severe mental illness (e.g., Amri & Bemak, 2013) such as psychosis or people with a forensic history; mass media often depict people with mental health problems as dangerous and unpredictable (e.g., Overton & Medina, 2008). Mental health support in the MENA region is also often associated with being locked up in an asylum (e.g., Amri & Bemak, 2013; Youssef & Deane, 2006). Asylums were introduced during periods of British and French colonialization and lacked standards of psychiatric care (Fernando, 2014). Research in Egypt indicated that mental illness can be perceived as a threat to social order, which is managed by the segregation and physical isolation of psychiatric facilities (Coker, 2005). Some comments made by group participants follow.

Language barriers

All Arabic-speaking participants reported language as a major barrier and stated their need to express themselves in Arabic and that they could not express themselves emotionally or fully in English (Abu-Ras, 2003; Arday, 2018; Memon et al., 2016; Mind, 2013a; Youssef & Deane, 2006). They expressed feeling uncomfortable having therapy in English or via interpreters:

Delivering therapy in a formal manner makes them feel like “a sick person”

All reported that they would reject help if therapy was delivered in a formal manner where they felt like “a sick person.” They appeared to feel like “a sick person” if the helping professional related to them from a position of formality which drew attention to their professional role. It appears that they experience the professional “doctor”—client “sick person” dynamic disempowering, and therefore they opt not to seek therapy. Memon and colleagues (2016) and Arday (2018) found that ethnic minority clients in the UK experienced the relationship between the healthcare provider and service user as centered on power and hierarchy, which created barriers for them to accessing mental health services. Hassan and colleagues (2016) found that many Syrian clients found the expert position of the mental health professional disempowering. Participants describe below their need for mental health care to be delivered informally and in a way which is sensitive to the power dynamics.

Mistrust

A major barrier reported was their lack of trust, which may reflect their negative perceptions of mental health services (Arday, 2018; Keating & Robertson, 2004; Youssef & Deane, 2006), or confidentiality concerns (Youssef & Deane, 2006). Many people from the MENA region come from countries with punitive and oppressive governments that routinely conduct surveillance. Furthermore, Mind (2013 cited in Arday, 2018) highlights how ethnic minorities in the UK increasingly encounter surveillance in public spaces. Younis and Jadhav (2019) highlight how Muslims also encounter surveillance in public spaces in the UK including healthcare settings which may impede access to health care. The women also expressed a mistrust in all statutory services including the NHS following the fire, with difficulties discerning between services and providers, which may also explain these findings.

Perceiving/experiencing therapists as not understanding their culture and religion

All referenced the importance of having therapists who understood their religion and culture and requested their religion to be incorporated into psychological interventions (e.g., Bagasra & Mackinem, 2014; Gilbert & Parkes, 2011; Yamada et al., 2019). Consistent with the literature, participants reported a lack of culturally appropriate mental health services (Arday, 2018; Grey et al., 2013; Mind, 2013a; Mental Health Foundation, 2018; Woods-Giscombe et al., 2016). Some expressed the interventions on offer by mainstream mental health services and therapists in general as lacking an understanding of their culture and religion, therefore they did not consider therapy as relevant or relatable to them.

Outcome 1: Improved community engagement and stigma reduction

Participants reported wanting psychological support that they could relate to otherwise they would have disengaged. By incorporating their language, faith, and culture into the intervention, all participants reported experiencing the intervention as relevant and relatable. Participants expressed that having therapists who were familiar with their culture and religion helped them to engage.

Participants expressed the relief they experienced in being able to express themselves in their mother tongue.

Participants were unanimous in wanting therapy delivered informally. Some appeared to hold preconceived negative ideas about therapy. All expressed that an informal therapeutic approach helped them to feel comfortable because therapy was being delivered without them feeling like they were receiving therapy; an informal approach may have addressed the stigma and shame attached to mental health and accessing therapy. This suggests that the Hand of Hope, an informal culturally appropriate faith-informed therapeutic intervention may be acceptable to communities who are not amenable to therapy in the traditional format that is delivered within mainstream mental health services. The use of food and the group facilitators cooking and eating with the group appeared to help add to the informal set up of the group.

Based on anonymized feedback, 86% reported that taking part in the group helped them to be more open to having individual therapy should they need it (57% strongly agreed, 29% agreed and 14% were neutral). We also accessed additional MENA-origin Muslim individuals who did not attend the group, perhaps due to the changed attitudes of the group members. This included eight of their bereaved children and two of their adult family members/friends who accessed therapy. Prior to the intervention, only two individuals were accessing individual therapy via the NHS GHWS. After the intervention, 20 individuals accessed therapy with a 100 percent retention rate for all; five of the most affected group members accessed individual therapy (see Figure 1). The qualitative feedback reported improved attitudes toward therapy, and the number of individuals accessing therapy would suggest that the intervention helped challenge the shame and stigma attached to mental health and seeking therapy and improved access to mental health services. It also highlights the benefits of coproduction and culturally adapting interventions to improve access to services, service experience, and engagement and retention of ethnic minority and faith groups (e.g., Mir et al., 2013, 2015, 2019; Nagel, Robinson, Condon, & Trauer, 2009; Perry et al., 2019; Soto et al., 2018; Thompson et al., 2018).

Figure 1: Improved access to mental health services

Outcome 2: Fostering of safety, stabilization, building of trust, greater mental health awareness, and improved emotional regulation

Based on anonymous ratings, 72 percent of participants reported feeling more able to manage any difficult or unpleasant feelings since taking part in the group (the remaining rated neutral); this would suggest that the group intervention supported stabilization and improved emotional regulation. Based on anonymous ratings, 86 percent reported gaining a better understanding of grief and trauma and how it affects them since taking part in the group (the remaining rated neutral).

Most reported finding the group “atmosphere relaxing”. They reported feeling more “relaxed” and “relieved” since taking part in the group and using the space to explore their difficulties.

Participants reported trusting the therapeutic space created, addressing the barrier of mistrust discussed earlier.

Outcome 3: Benefits of cooking activities on wellbeing

All reported that the group cooking activities helped improve their wellbeing, as noted by Farmer and colleagues (2018) and IASC (2007). Participants reported finding the cooking activities enjoyable, therapeutic, and relaxing, with many likening it to being at home with their family; it helped facilitate bonding, creativity, expression, and a sense of accomplishment.

Outcome 4: Strengthening of social support networks and reduced social isolation

All reported that taking part in the group reduced their social isolation and loneliness and increased communication with other group members outside of the sessions.

Most referenced experiencing the group as like “family.” Perhaps the strengthening of their relationships was supported by the facilitation of culturally familiar coping strategies—communal gatherings over food.

In the next section we outline the second Hand of Hope therapeutic group intervention and the service evaluation for this group intervention.

Community consultation

A second Hand of Hope group intervention was coproduced with a different group of women, as part of the Together For Grenfell project. For the second Hand of Hope therapeutic group intervention, the group requested to focus on their religion, the seerah, stories of the prophets, and to engage in traditional arts. The group comprised of six Arabic-speaking MENA-origin Muslim bereaved women, affected by the Grenfell Tower fire tragedy, who had witnessed the fire, had historic or current trauma symptoms in connection to the Grenfell Tower fire (based on assessments from individual therapy or contact with services), and had lost multiple close friends in the fire. All reported having no family in the UK. Most of the women were known to NHS GHWS and Al-Hasaniya Moroccan Women’s Centre through previous outreach efforts, or previously accessing individual therapy, and were invited to join the group; some women joined through word of mouth via the group members. We held a lunch and invited the group of six women to identify the group’s needs and discuss coproducing a group intervention.

The women reported being low in mood, not engaging in life like they did prior to the fire, and feeling socially isolated. The intervention involved nine weekly 90-minute sessions and ran from April to June 2019, 22 months after the Grenfell Tower fire. The second coproduced Hand of Hope therapeutic group intervention was run in partnership with NHS GHWS (adults service) and a third sector organization Al-Hasaniya Moroccan Women’s Centre. The group was coproduced and co-facilitated by the first and third author. The group sessions were focused on the following cultural healing practices: communal gatherings over food, seerah oral storytelling and Qur’anic stories of the prophets, and group nasheed singing and traditional drumming (Muslim women’s choir; see Table 3.). The adaptations outlined in Table 1 were applied with this group. The aim of the intervention was to strengthen resilience, promote behavioral activation, and improve wellbeing, mood, positive coping, and social support.

Outline of Hand of Hope therapeutic group intervention two

The first two session carried the theme of “Engagement and Consultation” and focused on building trust by exploring the religious concept of amanah (trust), establishing relationships and a group contract, facilitating group bonding and engagement via group activities and icebreakers, identifying the group’s needs and coproduction.

Session 3, “Sources of Resilience and Self-Soothing,” explored their interests, ways they manage stress and self-soothe (including faith-informed grounding techniques), nightmare and anxiety management, and religious resources that promote self-regulation and resilience. The aim was to promote stabilization, self-soothing, social connectedness, symptom management, and positive coping.

The fourth and fifth sessions emphasized the seerah, the life of Prophet Muhammad and his experiences of multiple traumatic events: exile, oppression, poverty, hardship, losing his parents as a child, death of his companions and children, and the ‘year of sorrow’ deaths of his wife and uncle. We explored his grief and trauma responses and expressions of sadness and distress. The aim was to promote positive forms of coping and resilience, reduce distress, normalize expressing distress, sadness and grief responses, and promote balanced thinking pertaining to negative religious coping and appraisals. These aims were extended to the following session content.

Sessions 6 and 7 exploring the life of Prophet Yusuf, focusing on his experiences of family betrayal, envy, injustice, oppression, exile, being subject to human trafficking and enslaved, and reuniting with his father. We also explored Prophet Yaqub’s grief response to hearing the news of his son’s death.

Session 8 provided an overview and psychological reflections on the stories of the prophets, with an emphasis on personal and psychological reflections on the stories of the prophets that were explored in previous sessions. We explored how the group felt about ending.

Session 9, “Group Ending/Marking Eid,” explored participants’ experiences of Eid without their loved ones and reflected on the group’s journey. The aim was to promote awareness and social connectedness.

Participants

All six group members were verbally invited to take part in the service evaluation. The five group members that took part in the service evaluation were British Arabic-speaking first-generation MENA-origin bereaved Muslim women, ages 41 to 84 years old, who were affected by the Grenfell Tower fire and had lost multiple close friends in the fire. Some of the participants experienced permanent displacement following the fire. One participant was unable to take part in the focus group interview due to other commitments. She was contacted individually to provide verbal feedback as part of the service evaluation; her feedback is included.

Methodology

The same methodology was applied as in service evaluation one (please see procedure and data analysis sections outlined in service evaluation one). A semi-structured focus group was held by the first and third authors in June 2019 with five group members, in both Arabic and English, which included the group members anonymously rating quantitative questions on a Likert scale.

Outcome 1: Improved psychological wellbeing, mood, healing, emotional expression and emotional regulation

All respondents anonymously reported that the group helped them in their journey toward recovery/healing, reduced their general and Grenfell-related distress, helped them to feel more relaxed and calm, and improved their psychological wellbeing, self-compassion, and emotional regulation. These results may be explained by the use of a faith-informed approach, cultural healing practices, and the activation of social support networks (e.g., IASC, 2007; Koenig, 2012; Salem-Pickartz, 2009; Somasundaram & Sivayokan, 2013). Trauma recovery can be propelled by practices which decrease self-criticism, promote distress tolerance, relaxation, and self-compassion (Turow, 2017). According to Koenig (2006), religion helps people to recover from a disaster because it provides meaning, motivation, hope, role models for suffering, a positive worldview, and psychological integration. Participants described valuing focusing on their faith and that it helped them to feel relaxed and happy. All rated the group activities as enjoyable, therapeutic, and mood enhancing.

Normalizing emotional expression using examples from Qur’an and hadith was reported to aid emotional expression, highlighting the benefits of integrating religious scriptures into therapy for religious Muslim clients (e.g., Azhar & Varma, 1995; Azhar et al., 1994; Mir et al., 2013, 2015).

Participants expressed feeling comfortable to open up. In the context of exploring this, some mentioned that the therapeutic alliance (Hubble, Duncan, & Miller, 1999) and the informal delivery of therapy sensitive to the power dynamics aided expression.

Consistent with the research literature on music therapy and choral singing, participants reported that drumming and singing improved their wellbeing, mental health, emotional expression and mood, and facilitated positive emotional states like relaxation and happiness (e.g., Bensimon, Amir, & Wolf, 2008; Clift & Hancox, 2001; Daykin et al., 2018; Dingle, Brander, Ballantyne, & Baker, 2013). It highlights the benefits of embedding enjoyable activities into psychological interventions to activate or strengthen positive emotional states.

All reported that since joining the group they were taking part in other enjoyable or meaningful activities outside of the group sessions. The intervention appeared to provide a form of behavioral activation.

Outcome 2: Personal growth, improved resilience and coping

All respondents reported that the group helped them to feel more resilient and able to cope with their difficulties, bereavement and traumatic experiences. Utilizing culturally familiar coping strategies may have helped promote coping (IASC, 2007). Religious beliefs have the potential to influence cognitive appraisals of negative life events, which can reduce distress (Koenig, 2012). As found in this service evaluation, religion provided a source of resilience and a resource for coping with difficulties (e.g., Hammad & Tribe, 2020a; Koenig, 2012; Nuwayhida et al., 2011; Thabet et al., 2013, 2015). It appears that the participants drew on stories of the prophets as examples of coping with difficulties (e.g., Hammad & Tribe, 2020a; Marie et al., 2017), which appeared to reduce their distress, challenged negative religious coping, and promoted wellbeing, positive outlook, resilience, and personal growth (Koenig, 2012).

Meaning-making promotes a new philosophy and cognitive appraisals about life (Hammad & Tribe, 2020b; Tedeschi, 1999) which helps facilitate emotional relief (Tedeschi, 1999) and has been linked with resilience (Hammad & Tribe, 2020b) and posttraumatic growth among disaster survivors (Weber, Pavlacic, Gawlik, Schulenberg, & Buchanan, 2019). All reported finding more meaning in their life since taking part in the group and greater personal reflection/development. The use of a faith-informed approach may explain these findings, as personal introspection is promoted and valued in Islam.

Outcome 3: Improved social support networks and reduced social isolation

All participants reported that the group strengthened social support networks, improved community connection and communication with group members outside of the group, and reduced their loneliness and social isolation.

Communal gatherings over food appeared to help strengthen social relationships and reminded them of family life. As referenced below, it holds special meaning in MENA cultures, whereby the act of eating together represents an implicit understanding that there is loyalty, care, and responsibility to look after the people they are sharing food with.

Outcome 4: Addressing language needs

Consistent with the literature, participants requested therapy in their first language (Arday, 2018; Memon et al., 2016; Mind, 2013a). Participants expressed their need for therapy in Arabic, as it helped them to retain information and express their emotions.

Summary and Conclusion

The aims of the Hand of Hope therapeutic group interventions were to: (1) identify and address the barriers to accessing mental health services for a group of British Arabic-speaking, MENA-origin Muslims affected by trauma and bereavement following the Grenfell Tower fire tragedy; (2) coproduce culturally appropriate therapeutic group interventions responsive to the needs of the Grenfell-affected MENA-origin Muslim community; and (3) to evaluate the impact of the Hand of Hope therapeutic group interventions, and whether it improved access to mental health services for the participants and their children aged under 18.

The service evaluation revealed participants encountered several barriers to accessing mental health services, which included: shame and stigma attached to mental health and seeking therapy, the formal format of therapy and language barriers, mistrust, and perceiving/experiencing therapists as not understanding their culture and religion. Participants requested informal, culturally appropriate, faith-informed therapeutic interventions delivered in Arabic. Adaptations were made to address the barriers reported and an informal trauma-informed therapeutic group intervention called ‘Hand of Hope’ was coproduced with the NHS GHWS, a third-sector organization Al-Hasaniya Moroccan Women’s Centre, and community participants. Utilizing cultural healing practices/collective culturally appropriate coping strategies and faith resources in the interventions was found to have psychological and social wellbeing benefits for disaster-affected individuals (e.g., IASC, 2007; Salem-Pickartz, 2009; Somasundaram & Sivayokan, 2013). Participants reported positive service user experience and that they found the Hand of Hope therapeutic group interventions helpful because it incorporated their faith and culture and was delivered in Arabic. The two interventions engaged different groups of bereaved MENA-origin Muslim women affected by the Grenfell Tower fire. Both groups consisted of women who had lost multiple close friends in the fire.

The first service evaluation found that the Hand of Hope therapeutic group intervention encouraged engagement and retention of MENA-origin Muslim participants who previously held negative attitudes toward therapy and challenged the stigma attached to mental health and seeking therapy. The large majority of participants reported positive changes in their attitudes toward therapy and went on to access individual therapy and their children in need also accessed therapy. The findings suggest that the intervention fostered stabilization, building of trust, greater awareness of mental health, improved emotional regulation, strengthening of social support networks, reduced social isolation, and the activities promoted wellbeing.

The second service evaluation found that the Hand of Hope therapeutic group intervention improved psychological wellbeing, mood, emotional expression, and emotional regulation and promoted positive emotional states (e.g., happiness, relaxation), recovery/healing, behavioral activation, resilience, the strengthening of social support networks, personal growth, and coping with trauma and bereavement. The intervention was found to reduce social isolation and distress including Grenfell-related distress.

Limitations and Challenges

Including pre- and post-outcome measures would have enhanced the intervention evaluation. However, the premise of the interventions was engagement and to have administered outcome measures prior to the intervention might have risked client disengagement due to the barriers reported by participants. It was not possible to have a control condition for comparison purposes due to the needs of the community to access timely and requested support, as per the disaster response remit. The small sample size limits the generalizability of the findings. However, these evaluations have contributed to several under-researched areas, including barriers MENA-origin and Muslim service users encounter in accessing mental health services in the UK, community engagement, partnership and coproduction, and culturally appropriate faith-informed therapy.

The focus groups were held by the group facilitators. This may have impacted on what the group members shared with us about their experience of the group, such as providing favorable feedback. Due to the levels of mistrust and wariness of services, it would have been inappropriate to have invited an external interviewer to hold the focus groups. We encouraged both groups to verbally and anonymously provide any negative feedback and areas of improvement, emphasizing that it was helpful for us to know what they did not like and what changes they thought were needed as it would help improve the future delivery of interventions. The participants did not provide any negative feedback or suggestions for improvements. They were very positive in their feedback, perhaps because we coproduced the intervention with them and consulted the group throughout the process, including checking in with the group during the sessions for regular feedback to ensure it was tailored and meeting their needs. One participant did ask for group sessions to run all day but the other participants responded that this would be difficult for them because they had young children.

There are always challenges when creating and delivering new interventions. Psychology and psychotherapy have been criticized for their Eurocentric approach and for imposing Western understandings of wellbeing and healing on non-Western cultures (Fernando, 2014). An emphasis on Eurocentric approaches to therapy and what therapeutic work is expected to look like in practice dominates and community interventions are often not given the same value or resources as mainstream therapies and are often not recognized as clinical work. Community work also evolves in a manner that makes it difficult to outline in advance what outcomes and experiences are likely (Bryne, 2020). Other challenges pertain to how religion and spirituality are divorced from therapy and rarely feature in Western therapy training, despite being a major resource for religious clients. Some colleagues were critical of us for working in a faith-informed way and misunderstood what working in a faith-informed way meant; this induced shame among some facilitators when sharing our work with wider services. It was challenging for some of the facilitators to work in this context as it created discomfort in doing things differently. We managed these tensions by trusting in the process and holding the position that the community are the experts. It also helped that we had shared culture and faith as the group members and that we were aware how important it was to honor traditional and religious customs and cultural healing practices following collective trauma and loss. We recognized the therapeutic value in social connectedness and restoring cultural healing practices. We supported each other via peer-supervision. We were fortunate to have culturally informed supervision and support from a supervisor with a shared culture and faith as the group members and support from senior managers who encouraged coproduced culturally appropriate therapeutic work with the community.

Implications

The Hand of Hope approach would be applicable to other minority ethnic and faith groups. To ensure a culturally competent service, training therapists on cultural and spiritual/faith elements is likely to help aid the engagement and retention of minority ethnic and faith groups in therapy. As with any successful therapeutic encounter, the therapist needs to be able to work with the client’s inner frame of reference; culture and faith are integral structures to the inner frame of reference for the majority of clients from the MENA and Muslim community. Therefore understanding and working with the client’s culture and faith will equip therapists with additional tools to be able to address clients’ issues in a way which can feel more holistic, acceptable, and meaningful to clients. For non-religious MENA-origin clients, the Hand of Hope group approach would still be applicable by concentrating on the MENA cultural aspects involving cooking and sharing food, and/or removing or replacing faith aspects. For example, stories of the prophets could be replaced with traditional cultural MENA stories and nasheed singing could be replaced with folk or classic Arabic songs or poetry.

Different ways of working are urgently needed to improve mental health and access to and experience of mental health services for minority ethnic and faith groups (e.g., Bhui et al., 2015; Lane & Tribe, 2010; Thompson et al., 2018). This service evaluation provides a positive example of an innovative intervention piloted with the MENA-origin Muslim community to address their cultural and spiritual needs following collective trauma and loss, and it improved access to mental health services for disaster-affected ethnic minority and faith groups. It adds to the growing body of evidence documenting the benefits of coproduction (e.g., Nagel et al., 2009; Zlotowitz, Barker, Moloney, & Howard, 2015), faith-informed therapeutic interventions for Muslims (e.g., Hook et al., 2010; Mir et al., 2013, 2015, 2019), and providing culturally sensitive therapeutic interventions to ethnic minority groups (e.g., Bhui et al., 2015; Hall et al., 2016; Soto et al., 2018). Partnership working between statutory services and third-sector organizations, community consultation to identify barriers to accessing services and making adaptations accordingly, and coproducing culturally appropriate faith-informed psychological interventions were found to improve access to mental health services, psychological and social wellbeing, engagement and retention in therapy, and service user experience for MENA Muslim communities.

Future research is encouraged to document the barriers ethnic minority and faith groups encounter in accessing mental health services, the process of coproduction, the cultural and faith adaptations made to therapy, and the outcomes. Often culturally adapted/appropriate interventions do not detail sufficiently the cultural and faith adaptations made which limits replicability. There is a need to develop and evaluate culturally appropriate psychological interventions tailored to specific ethnic groups which incorporates cultural conceptualizations of presenting problems and indigenous forms of healing; an awareness of the intersectionality between culture and faith is also needed in this regard. Future research is needed to develop outcome measures to measure the impact of community interventions.

Service providers have a responsibility to remove barriers to accessing services (Belyani & Marshall, 2020). As illustrated in this service evaluation, this can be addressed by first facilitating community consultation and engagement to identify barriers to accessing mental health services. Lane and Tribe (2010) encourage the use of food in community engagement interventions because it helps create a relaxed informal atmosphere. Second, establishing coproduction and partnership work between statutory services, community organizations, and community members is recommended to try to address the barriers to accessing mental health services and improve service provision for ethnic minority and faith groups. Local organizations are often the first point of contact for minority groups in need (DoH, 2009); they hold valuable knowledge concerning the health needs of the communities they serve (DoH, 2009; Lane & Tribe, 2010). There is a need to ‘work alongside’ the community as opposed to ‘working on behalf of’ (Bryne, 2020). Coproduction offers a way to engage and work collaboratively with the community on shared goals.