Explore mental health stigma and perception of counselling amongst British Muslims.
Mental health stigma is an ongoing issue that needs to be addressed especially amongst minority groups. Statistics show that’ one in four people will experience a mental health problem in the course of a year (mental health foundation 2015). The government has initiated to tackle mental health stigma that prevents people from accessing psychological services (Burstow 2011).Over the past decade the Muslim community has been portrayed negatively especially through the media, and this has had a profound affect on Muslim’s mental health. The purpose of this research is to explore mental health stigma and perception of counselling amongst Muslims in the UK, My interest in this research emerged from my own personal experience of living in a Muslim family where mental health is seen as an alien concept and counselling is seen ‘waste of time’. After experiencing a close family member suffering from depression and when given the choice of counselling chose to decline this, as they would rather take medication then be labelled as ‘crazy’. A growing population of 2.7 million Muslims in the UK (Census 2011) I feel that it is imperative to explore what type’s of mental health stigma exists in the Muslim community and their views on counselling in order to address them.
To search for articles I used SOLAR, selecting databases, which included Academic Search Premier, CINAHL and MEDLINE (Ovid). I did this so that the article that filtered through were relating to counselling, psychology, psychotherapy and mental health. The key terms that I used firstly was counselling, and this was grouped into four subgroups using the ‘OR’ which contained ‘counseling’, OR ‘psychotherapy’, OR ‘therapy’, OR ‘psychological services’. This brought up a result of 874.207, which was a very large result, but I felt this was needed to be done as counselling maybe worded different in research articles. I used key terms such as mental health, stigma, Muslims and perception all with sub groups (see appendix 1)
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Finally, I joined all the key terms and sub groups together using AND which brought the number of articles generated down to 604. I mixed some of the sub groups together to find variety of results because when I added all 6 categories together my results became very limited so therefore to broadened my research I took out two categories and I felt this gave me access to variety of research articles. Limitations also included all my articles needed to be peer reviewed, this was to ensure standard and quality of the articles were examined by other people in the same field to ensure the publication has a meets certain level of excellence. I also limited the publication dates from 2005 up to 2014 to generate current articles I found that lots of articles that had very close link to my question had to be excluded due to the publication date being before 2005. This process finally reduced the articles to 91 from which four articles were selected (see appendix two). I found some articles that related directly to my question but were mostly conducted outside the UK so only one article was selected because it felt necessary to look at research done in the UK considering my title involved British Muslims. The article selected from the USA was chosen because there did not seem to be any research conducted in the UK therefore was a gap to explore.
In relation to my question I felt my 5th article ‘ Rethink (2007), Our voice : The Pakistani communities view on mental health and mental services in Birmingham, was very relevant to utilize in my review as it provided an insight to what I was searching for. However the only down side to finding this articles was that it was not found using the above research strategy, as I read a mention of this study through another article and I could not find it on EBSCO, therefore I used Google to find it.
The articles will be judged the on the methodology used to conduct the research and focus on the findings relating to perception of counselling and mental health stigma.
A study conducted by Weatherhead and Daiches (2010) looked at Muslims view on mental health and psychotherapy. The aim of the research was to look at the Muslim population’s perception of mental health and their understanding of how mental distress experienced by an individual can be addressed. This was a qualitative study where 14 Muslim participants were interviewed using semi structured interviews and data was analysed thematically. Lancaster Institute of Health Research ethics committee ethically approved this study. There were seven women and seven male aged between 28-77 who were recruited through local Muslim organisations and electronic mailing.
One of the main benefits of this study was that it provided a good insight to Muslim’s understanding on mental health by using open questions allowing the participants to express their views on mental health in-depth. The finding that related to my question was that there was a fear of stereotyping, feeling stigmatised, embarrassed and ashamed, they found that mental distress was a punishment from god, cause of witchcraft/jinn and drug taking. Participants there was no need for a therapist as you could talk to your family or friends. Mental illness was seen as a test from Allah and it was managed through praying to god and if you had a strong faith then therapy was not needed. For a question, looking at Muslim population’s views the sample was very small even though it provided rich data it was limited as it was not enough to represent ‘Muslim’ populations view.
The sample also included two students and two staff members and a couple who were interviewed together, this makes the sample less representative and biased. Data check would have been useful as both researchers were non- Muslims therefore this may have had an affect on how they interpreted the Reponses and by data checking they could have validated their findings. The researchers recommendation for further research was a very useful, as by exploring the views of Muslims who have accessed mental health services would have gave the study a bigger picture, as the focus on therapeutic help was neglected in the study as only three participants had a view on this.
Another similar study conducted by Rethink (2007) Our Voice: the Pakistani community’s view on mental health and mental health services in Birmingham commissioned by UCLAN (University of Central Lancashire) and CSIP (Care Services Improvement Partnership). This aim was to investigate the view of the Pakistani communities on mental health issues and how they would want support in regards to their mental health needs. This study was a qualitative study conducted by 11 community researchers who conducted focus groups and interviews with a very large sample of 152 service users, this study utilized quantitative approach by distributing 30 postal surveys to mental health service providers in Birmingham and receiving seven responses. Rethinks research department and UCLAN ethically approved the study.
This study found similar findings to Weatherhead and Daiches (2010) they found that 83% wanted to keep any mental health illnesses a secret, and 76% were ashamed of it, 58% fear of stigma. They also found religious beliefs affected their perception on mental health as they felt it was caused by jinn’s, voices from god and found that culture and language barriers can get in the way people from accessing mental health services.
One of the benefits to this study compared to above is that this study was conduced in different languages so therefore this was accessible to people who could not participate because of language barrier. Another benefit of this study compared to the Weatherhead and Daiches (2010) study was the sample size as they had a larger sample 152 compared to 14 participants in Weatherhead Daiches (2010) study. However, Rethink (2007) even with a big sample it could be argued that it was a limited study which only focused on Pakistani Muslims in Birmingham whereas Weatherhead and Daiches (2010) study had a small sample of participants but from different nationalities . However, both studies failed to consider demographic area such as different ethnicities and different locations that could have provided a more in-depth representation of British Muslims perception.
The one of the recommendations from the study that stood out and was missed in the first study was the suggestion of working closely with religious leaders such as imams, it felt in both studies religious influence was a huge factor yet both studies failed to get the perception of imams on mental health. It was also relevant to my research as this project highlighted the mental health stigma issues that are current in the Pakistani Muslim community in Britain however, I felt that no emphasis was given on perception of counselling and I feel this was a gap in the research.
Another similar study to Rethink (2007) was a study conducted by Shoaib and Peel (2006) which looks at Kashmiri women’s perception of their emotional and psychological needs, and access to counselling. This like Rethink (2007) study used both qualitative and quantitative method to analyse data, the sample was of 45 Kashmiri women aged between 18- 45 living in Oldham, from whom 19 were born in the UK. A questionnaire was administrated and data was collected in an interview by a researcher that was also Kashmiri and spoke the same language as the participants, this was one of the strength of the study as this eliminated language barriers. This study explored six areas in 21 questions: understanding of mental illness, issues that cause distress, coping mechanism, awareness of support, expression and description of feeling (Shoaib and Peel, (2006). The reason this article was selected because the 6th area looked at perceptions and understanding of counselling that was relevant to my question.
The findings were very similar to the above studies, the study found that women feared of shame (izzat) affecting their family and being stigmatised. It was found that talking to a specialist was an option but fears of confidentiality breaking, lack of cultural awareness from the professional and that it will not improve the situation was a barrier therefore they referred to their faith for healing.
This study like the other two provided a good insight to views of mental health stigma but also provided a glimpse into the perceptions of counselling which the other two studies failed to do. There are few limitations, the potential source of bias would be the use of the snowball method in recruiting 35 participants, who were recommended through previous interviewees, and therefore there is a possibility that subjects shared the same traits and character. Another limitation is the research may be flawed by the inexperience of the researcher who at the time of the research worked as a welfare officer. Changes need to be made to the recruitment process in order to get a more representative sample.
Two others studies which explored factors influencing attitudes towards seeking help within the mental health services where reviewed. The first study I looked at was by Soorkia et al (2011) which explored Factors influencing attitudes towards seeking professional psychological help among South Asian students in Britain. This study looked at the link attitudes towards psychological help seeking, following cultural values, salience of ethnic identity and cultural mistrust (Soorkia et al, 2011) .this study was relevant because it looked at attitudes towards seeking help and this relates to my question of perception of counseling and mental health stigma. A quantitative approach utilized where 148 participants completed a survey of which 81 were women and 67 men all participants were British. The sample covered Pakistani, Indian, Bangladeshi and 30% were other. Participants were recruited though public spaces directly and sign up sheets were posted in campuses in different locations. Questionnaires where given out on paper and participants returned the questionnaire in a sealed envelope to researcher (Soorkia et al, 2011). Priory power analysis, SPSS and ANOVAs was used for statistical analysis, as these were the most affective to see the difference between gender, ethnicity and also to compare similarities (Soorkia et al, 2011).
It was found that the ethnic minorities had a negative attitude towards seeking psychological health, and factors such as cultural values and mistrust as this was related to stigma and shame associated mental illnesses. it found that people that were mistrustful of whites held a greater negative attitudes to help seeking. Asian values played a significant part in peoples attitudes towards seeking professional psychological help (ATSPPH), (Soorkia et al, 2011). The more significant the values were the more it played a negative part in ATSPPH. The study also found that women were more open to getting help than men and this maybe due masculinity being dominant there negatively affecting the way men see health related issues. It seems that this could be explored in more depth to see what the underlying issues are that prevent men in seeking help compared to women. However the limitation to the comparison between genders was that this could not be representative as there was not an equal number between both genders. Sample size was small therefore, it did not represent south Asian students across the country. It feels that even though participant’s religion was noted that the study failed to explore if religion played a part in help seeking. It seemed like the study could have looked at what the cultural factors were or the Asian values in order to understand the barriers to combat. It seems like this study was s stepping stone to see what the factors where but a qualitative approach will give this study more depth.
The second study I looked at was very similar to the first study and it was by Hamid, &Furnham (2013) which looked Factors affecting attitude towards seeking professional help for mental illness: a UK Arab perspective. This research like the above was also quantitative where online questionnaires were used; the sample size was 204 participants from which 104 were British Caucasians and 100 Arab.
This study looked at various factors affecting attitudes towards seeking professional psychological help (ATSPPH). Some of the hypothesis was that Arabs compared to Caucasians will be less positive to ATSPPH and arabs sample will have higher score in supernatural causes, shame focused attitudes will be significant predictors of ATSPPH , females more positive than males in ATSPPH and Muslims will have less positive than other religion (Hamid, &, Furnham 2013). To analyze the data a discriminative analysis was utilized with ethnicity being the dependant variable between British Caucasian and Arabs, using discriminative analysis was a benefit as it reduced mistake rates (Falkenberg, 2005). To examine differences between British Caucasians and Arabs same as the previous study ANOVA was used( Hamid, &, Furnham 2013).
The study found that Arabs were less positive to ATSPPH than British Caucasian as the study predict ed , it was also found that age, level of education and experience of metal played a positive role to ATSPPH (Hamid, &Furnham 2013) . It also found that Arabs had strongest supernatural casual beliefs about mental illness than British Caucasians. Unlike the above study this research found that gender was not a significant predictor, however it was similar to the other study in the sense that there was also not an equal number of males and females as in this study 69% were females. Shame was not seen as a significant predictor to ATSPPH that is opposite to the finding in the above studies. This maybe connected to the fact that Arab participants had migrated to uk and therefore far from family so they did not have to protect their honour or family (Hamid, &Furnham 2013). One of the limitations to this study was that the questionnaire was done in English and therefore only targeted an audience where participants had some form of education, therefore it does not represent the Arab community who do not speak or understand English making it bias and limiting its response rate.
I then looked at a quantitative study by Pilkington et al (2010) which explore factors affecting intention to access psychological services amongst British Muslims of south Asian origin. Second study by Ali et al (2005) looking at the Imam’s role in meeting the counselling needs of Muslim communities in the United States. Both studies used self-report questionnaires.
The study by Pilkington et al (2010) Hypothesised that the level of shame/izzat related with mental health would predict the intention to access psychological services, the barrier was already identified compared to the above studies. This study was relevant because it looked at British Muslims, which relates to my area of proposed research and explored mental health and barriers that related to stigma. The Identified factors that may affect intention to access psychological services were; religious beliefs, biological /social environment beliefs about mental health problems, the causes and shame/izzat. Another large sample of 94 participants recruited through seven Islamic communities’ centres. A self-report questionnaire was developed using measures that were already tested making this a strength as it was easy to correlate the findings and therefore strong statistic were produced. Psychological openness and help seeking prosperity was measured using Inventory of attitudes towards seeking mental health services (IASMHS: Mackenzie et al 2004). Shame/izzat on intention influencing the access of psychological services was measured using the Attitudes Toward Mental Health Scale (ATMHP; Gilbert et al 2007).
The study found that the higher level of shame/izzat experienced the less likely psychological service was accessed. The study like the other studies above found views were influenced by religious beliefs, mental illness was a punishment from god, shame to the individual and the family and less knowledge about mental illness because of lack of education(Pilkington et al, 2010). The limitation to this study was that there might have been a bias to the recruitment process, as the questionnaires designed was for people of higher education level therefore resulting in a low response (Pilkington et al 2010). Another limitation was that participants were recruited through Islamic community’s centres, therefore they may have been more religiously inclined then others who are Muslims but not as religious, this limits the experiences and results. I feel this was gap to where the level of religious commitment could have been measured to get effective results.
I then looked at two studies that focused on the role of imams in regards to mental health. The first study by Ali et al (2005) explores what the role of imams and Islamic clergy is in meeting counselling needs, the reason I chose this was because I found that all the studies that I have reviewed failed to consider the views of Islamic clergy on mental health and counselling and how they support the Muslim community. A questionnaire was mailed to 730 mosques around USA however; the response rate was low as only 8% responses received. Data was analysis measured by Likert scale, demographic areas were considered such as ethinicty, age and region, and consent was gained. This study found that imams played a key role in supporting the Muslim community with mental health issues relating to stress, discrimination, anxiety and financial problems. It also found that imam has had little or none training in counselling to help people who came to them for mental health problems. The limitation to this study like the above study is that the questionnaire was in English and not all participants or imams are literate in English, therefore weakening the study. I found the recommendation from the researchers is valid that a further research is needed to explore the role of imams in assisting with mental health issues.
The second study by Abu-Ras et al (2008) explored The Imam’s Role in Mental Health Promotion: A Study at 22 Mosques in New York City’s Muslim Community. the reason this study was chosen because this provided an insight to not only the imams role but also what the worshippers attitude towards mental health services before 9/11 and after 9/11 (Abu-Ras et al 2008). A survey of 22 imams and 102 worshippers from 22 mosques in New York city was conducted, researchers chose a face-to-face interview method with mostly close ended questions.
The questionnaire for the imams explored what type of issues worshippers came with for guidance, and what method were used to assist worshippers resolve their issues. The questionnaires for worshipers looked at the role of the imam perceived by worshippers, types of counselling sought at mosque, if the imam was effectively addressing their issues. It also asked the affects of 9/11 to their personal lives and finally worshippers perception on attitudes towards western psychology, mental health and if they have any experience with the mental care system (Abu-Ras et al, 2008). For analysis, Univariate and bivariate analyses were used for descriptive statistics for both imams and worshippers. The t test and chi-square tests were applied to discover any large differences between gender, age, time in education, income, immigration status, marital status, and language skills (Abu-Ras et al, 2008).
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The study found that imams are usually the primary and sometimes the only contact for help with mental health issues. It was also found that the imams were foreign born and English was not their first language and they struggled with their English and No training was provided and they had little knowledge on mental health issues, which then prevented them from referring worshippers to mental health services (Abu-Ras et al, 2008). This was very similar to the finding of the above study were the imams had the same issues of language barrier and little or no knowledge on mental health. The study also found that 9/11 had a negative affect on worshippers lives this included their self as well their families. It also found that 84% of worshippers believed that people with mental illness were possessed by the devil and 95% believed that this was test from their faith (Abu-Ras et al, 2008).
The limitation to this study was that data was only limited to New York so it did not represent other Muslims in the USA, same as the above study the questionnaire was conducted in English, and imams had difficulty with English so it brings up the issues of reliability . The benefit of this study was that it found that imams do play a vital role within the Muslim community in New York especially when it came to personal and mental health issues and that they were also welcomed support and training in regards to mental health. The researcher’s recommendation was very prompt that the mental health services need to do more to integrate within the Muslim community especially by providing support and training to imams because this research has shown that imams play a huge role in providing support.
It was found from the literature review that mental health stigma is very much alive in the Muslim community, in the form of misconceptions around the causes of mental illness, fear of being labelled and stigmatised, religious and cultural views influencing views on mental health e.g. punishment from god for committing a sin. The majority of the Muslim community would rather keep mental illness quite because of the fear shame, some seen mental illness caused by drug abuse or caused by witchcraft.
In relation to my proposed question I found that there were number of gaps that were found that I could use in my research firstly their was a common theme of religion being a major factor in influencing views on mental health. However not one paper focused on measuring religiosity and its impacts on individuals perception, they focused more on ethnic backgrounds such as south Asian origins which is not religion. Findings showed Muslim community turned to religious leaders for support, yet no papers in the UK explored the role of Islamic clergy on mental health and their views on counselling. I feel this could provide a clear picture around what support is available and how much experience the imam’s have in supporting the Muslim community.
I found that Papers do not specifically address the issue of counselling, I felt that this could have been explored in more depth also one of the recommendations was to look at participants that have accessed counselling and explore their perception on stigma and therapy which I found useful for my research. I feel that for the question I have proposed qualitative methodology would be more appropriate as it provides rich data and allows participants to expand on their responses. I also found that demographic factors need to be taken into consideration, such as age, gender and location, and to look at factor such as sample size and recruitment process.
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Ali, O. M., Milstein, G., Marzuk, P. (2005). The Imam’s role in meeting the counselling needs of Muslim communities in the United States. Psychiatric Services, (2), 202-205.
Burstow, P. (2011). £20 million to knock down mental health stigma, retrived from //www.gov.uk/government/news/20-million-to-knock-down-mental-health-stigma
Census, (2011) retrieved 19 January, 2015, from: //www.ons.gov.uk/ons/rel/census/2011-census/key-statistics-for-local-authorities-in-england-and-wales/rpt-religion.html
Mental health foundation, (2015), retrieved 19 january, 2015, from //www.mentalhealth.org.uk/help-information/mental-health-statistics/
Pilkington, A.,Msetfi,R,.M,.Watson,R. (2012). Factors affecting intention to access psychological services amongst British Muslims of South Asian origin. Mental Health, Religion & Culture, (1), 1-22. doi: 10.1080/13674676.2010.545947
Rethink (2007), Our voice: “The Pakistani community’s view of mental health and mental health services in Birmingham.” London: Islamic Human Rights Commission. ) Retrieved 29 December, 2014 from: //www.rethink.org/media/853081/our%20voice.pdf
Shoaib, K.,Peel, J. (2003). Kashmiri women’s perceptions of their emotional and psychological needs, and access to counselling. Counselling and Psychotherapy Research, (2), 87-94. DOI: 10.1080/14733140312331384442
Weatherhead, S., Daiches, A. (2010). Muslim views on mental health and psychotherapy. Psychology and Psychotherapy: Theory, Research and Practice, (1), 75-89.
//people.eku.edu/falkenbergs/psy862/notes%20on%20discriminant%20analysis.html 2005 Steve Falkenberg
Abu-Ras, Wahiba, Gheith, Ali and Cournos, Francine(2008)’The Imam’s Role in Mental Health Promotion: A Study at 22 Mosques in New York City’s Muslim Community’,Journal of Muslim Mental Health,3:2,155 – 176
The next key term was ‘mental health’ using two sub group using OR was ‘Mental illness’ and ‘mental health services’, this generated 525,281 results. Another key term was ‘stigma’ and the sub groups using OR was ‘attitudes’, stereotypes’, ‘prejudices’ and ‘shame’. The next key term I felt was important to my research was ‘Muslims’ I tried this on its own but then realised that there can be other terms used in researches referring to Muslims and I used three sub groups which were ‘Islam’, ‘ethnic minority’, ‘south Asian’ and this generated 89,716 results.
Another key term was ‘perception’ and I used three key terms ‘view’, ‘understanding’ and ‘intention’ and this generated 2,456,725 results which was huge but I felt that this was necessary as this bought my question together. my last key term that I used was ‘Britain’ and I used two sub groups ‘British’ and ‘UK’, this was to focus on the researched done on the British population as I felt it related to my question more.
Examples of articles found