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Predating Sigmund Freud by 1,000 years, talk therapy was initiated by Rhazes (Abu Bakr Muhammad Bin Zakariya Ar-Razi), a 9th Century Islamic physician who lived in Persia and is regarded as one of the founders of clinical medicine (Heartbeats, Winter 2008).
Islam is one of the fastest growing religions in the United States, but there is conflicting data on the group’s size and demographics. Estimates of size range from 11 million, to 5 million, 2.8 million, and 1.6 million (Pew, 2007; ASARB, 2000). The best estimate places the total number between 2.5 and 4.4 million (Nimer, 2002).
About four-fifths of American Muslims are approximately evenly divided among three groups: African-Americans, Arab-Americans, and South Asians (Bagby, 2001). The remaining fifth are of African, East Asian, European, Caribbean, and Latino descent (Qamar-ul Huda, 2006). There are many U.S.-born Whites of Western European descent, who may not present as a "stereotypical" Muslim, but do in fact follow Islam (Pew, 2007). The Muslim community in America is diverse, with first- and second-generation immigrants, as well as those who trace their origins to the early days of colonization of the Americas.
In general, Muslims tend to settle in existing communities in New York, Washington, California (especially Los Angeles and San Francisco), Texas, and in a region between Chicago and Detroit (Pipes, 2002). Muslims tend to settle in large metropolitan areas, where they find others with similar ethnic ancestry. For instance, in Detroit, the Muslim population is primarily Arab; in Los Angeles, it is primarily Iranian.
Unlike other cities in the U.S., New York City is a place where the worldwide Muslim community is fully represented (D’agostino, 2003). ASARB (2000) estimates that there are 167,259 Muslims in NYC who identify with a specific mosque group. Because of the de-centralized nature of Islam and the large proportion of Muslims who do not identify with a particular group or mosque, many self-described Muslims may not be counted in this estimate. If they were to be counted, the estimate would increase to approximately 600,000. In 2000, Muslim adherents were spread through the five boroughs in the following way: 57,897 (2.35%) lived in Brooklyn, 37,078 (2.41%) lived in Manhattan, 52,038 (2.33%) lived in Queens, 8,082 (1.82%) lived in Staten Island, and 12,164 (0.91%) lived in the Bronx (ASARB, 2000).
Muslim immigration history traces the group’s arrival to the United States to the 1600’s during slavery (mostly from Africa). Because of discrimination against Muslims among slave-owners, many Muslim slaves were unable to practice their religion with and teach their heritage to their children. Consequently, just two generations after their arrival the practice of Islam among slaves had been dampened (Pipes, 2002). Nevertheless, from around 1875 to 1924, Muslims (particularly Levant Muslims) began immigrating to America in increasing numbers. It was not until 1965, with a landmark immigration law that liberated U.S. restraints on family reunification, that Muslims again began coming to the US in large numbers. It was during this latter part of the 20th century that 87 percent of mosques were founded in the United States (Bagby, 2001).
Prevalence rates of mental illness
There are no large-scale U.S. epidemiological reports on prevalence and incidence rates of mental illness unique to Muslims. For this review, we extrapolate from international studies, data that might be applicable to recent immigrants. Ihsan Al-Issa (2000) reviewed the existing international epidemiologic data on several disorders and conditions, concluding that the rate of schizophrenia in Muslims is similar to that of non-Muslims. Higher rates of depression in women versus men - as seen in U.S. populations -are also seen in Muslim populations. Although anxiety disorders seem to be as prevalent in Muslims as in non-Muslims, high rates of PTSD were found in both Muslim men and women facing post-9/11-related trauma and discrimination (Abu-Ras & Abu-Bader, in press).
In dealing with suicide, disentangling psychopathology, religious beliefs, culture and sociopolitical situations could be difficult for a clinician. Suicide is strictly forbidden in Islam because it supposedly curtails the possibility of entrance into religious Paradise. Generally low suicide rates are seen across international studies but are not necessarily comparable to data in the U.S. (Murty, 2008; Zakiullah, 2008), particularly since suicide abroad may not be reported due to fear of stigmatization. While low rates of completed suicides are reported in Muslim countries, ideation and attempts are relatively high, particularly in young women experiencing intergenerational conflict. On the other hand, as Grimland (2006) suggests with regard to the phenomenon of suicide bombing, "suicide is instrumental in the context of war, not in the context of psychopathology.” A client’s reference to "jihad" could thus be misconstrued. Greater jihad is the self-reflective struggle toward improving oneself through devotion to one's religion. In that sense, any client who perceives his mental health as related to his spiritual health might view coming to the provider as steps toward jihad. Jihad viewed as the sanctioning of violence in opposition to aggressors in the specific context of war would be less likely related to psychopathology.
The low rate of alcohol abuse in Muslim countries appears to be true for adherent Muslim populations in the United States (Hanolt, 2006). However, Muslims born in the U.S. are more likely to drink than immigrant Muslims (Haddad, 1987). Perhaps because drinking alcohol is taboo, Muslims who do drink are less likely to report their use out of shame. Use of tobacco and culture-specific psychotropic substances is more rampant and problematic (Zaman et al., 2004). Ethiopian Muslims chew khat, a tea-like plant used recreationally for its release of amphetamine-like substances (Alem et al., 1999) and South Asians chew areca nut (in the leaves of betel nut plant) (Croucher, 2002), which, when combined with smokeless tobacco, raise cardiovascular disease risk factors (Gupta, 2002). The use of hooka, is becoming increasingly popular among Muslims and the broader American community. The content can vary, but may include tobacco, herbs, marijuana, or hashish. Given the accessibility and availability of alcohol and other substances in the U.S., the clinician should always inquire about substance use (including alcohol, tobacco, narcotics and other legal foreign psychotropic agents) independent of the degree of acculturation or religious devotion.
Cultural views of mental illness
Role of Religion
Muslim religious beliefs have an impact on the mental health of individuals, families and communities, and are considered a central component of identity (Nasser-McMillan, 2003). Importantly, individual behavior is thought to impact others and is considered in a community-context. The teachings of Islam provide a comprehensive way of attributing meaning and purpose to everyday life. The Qur’an, “the word of God,” serves as “a guide and a healing to those who believe” (Qur’an, 41:44). The Hadith (traditions and sayings of the Prophet Mohammed) also provides guidance for moral and ethical behavior. Following Islamic directives is believed to promote a high quality of life and a healthy mental state (Qur’an 2:177). Devout Muslims believe that adherence to the principles outlined in the Qur’an and the Hadith serve as prevention and treatment for emotional disturbances. The Qur’an considers a number of psychosocial issues, such as care for the ill, marital and family relationships, child-rearing, honesty, justice and modesty. It is not considered a substitute for prevailing medical knowledge, but because original scripture is in Arabic and may include parables, individuals and mental health providers often consult religious leaders for interpretation.
Most Muslims seek informal help from imams on a variety of issues, including mental distress. Imams nationwide, report that their congregants come to them for a full range of emotional problems, marital and family problems, and psychological and social concerns (Ali et al., 2005). One hundred percent of imams reported an increase in help-seeking following 9/11 (Ali et al., 2005).
Views of psychiatric illness
Muslims have a broad range of beliefs about the cause of mental illness, but by virtue of religious belief attribute the ultimate cause of everything, including disease, to God. Believing illness is punishment from God for some wrongdoing influences some Muslims to take a passive attitude towards dealing with afflictions. Clinicians might find it beneficial help patients understand proximate causations without discounting their belief in ultimate causation.
Traditional Islamic teachings explain mental illness in a variety of ways: as a defective relationship with God, as a punishment from God, or, simply, as the imponderable result of God's will (Al-Krenawi & Graham, 1999). Mental illness is part of human suffering and often regarded as a way of atoning for sins. Reward may be greater if suffering is endured with patience and prayer. Illness or disease is also believed to be a divine test of the level of piety, devotion, and loyalty of the faithful. Abu-Ras & Abu-Bader (in press) reports that 98% of survey respondents asked about perceptions of mental illness agreed that life stressors are a test of one’s faith. 84% of respondents believed in devil possession of mentally ill persons. It is believed that when alternate beings, such as Jinns, possess individuals, hallucinations, delusional beliefs and disorganized behavior may result. Other purported supernatural causes are black magic and the evil eye. Some believe that envy (intentional or not) can invoke negative consequences and charms, markings, jewelry, prayers or rituals are used to distract jealousy and envy. Curiously, beliefs and practices pertaining to demonic possession, witchcraft, black magic, and the use of exorcists, charms and magic potions are not condoned or supported by the Qur'an or the Hadith.
Mental health care seeking patterns
Use of religious and spiritual interventions
Muslims believe that religious and spiritual interventions, as well as efforts to integrate back into the community, are an essential part of supporting someone with mental illness (Khan, 2006) or during traumatic times (Ai, 2005). Ninety-five percent of the respondents in Abu-Ras & Abu-Bader’s (in press) study believed that an emotionally disturbed person could be cured by studying the Qur’an and the Hadith. To promote healing, excessive ritual acts of devotion, such as prayer (salat), fasting (sawm), repentance (tawaban), and recitation of the Qur’an (zikr) are adopted.
Religious Muslims self-report better mental health than non-religious (Abdel-Khalek, 2007; 2008). The Pakistani Muslim population in America believes that religiosity, followed by ethnic identity and socio-economic status, is the best predictor of subjective well-being (Mehvash, 2007). Formal prayer and its antecedents (cleanliness rituals), performance requirements (concentration, daily structure, physical exertion) and embedded practices (supplication and meditation) are thought to be beneficial, particularly when performed in groups.
According to Islamic thought, mental and spiritual development is in a constant state of evolution, starting from a purely self-gratifying stage (“nafs i ammareh”), and progressing to a stage of inner peace and self-assuredness (“nafs i mutma’enneh”) (Mohit, 2001). During this evolution, the individual passes through periods of self-doubt, self-accusation and self-acceptance to reach the pure self, and finally, the ultimate peaceful self. This therapeutic process is called “Tazkiat Alnafs” (Mohit, 2001), and it uses elements of cognitive, behavioral and psychodynamic therapy. Typically, imams guide worshippers through the process to help them overcome distress.
Use of professional services
Islamic tradition fosters the idea that there is a cure for every disease. Hence, Muslims tend to have positive attitudes toward professional help-seeking behavior (Al-Krenawi, 2004). However, knowledge and familiarity with formal services, perceived social stigma, and the use of informal-indigenous resources often hinder use of professional services in the U.S. (Aloud, 2004). Concerns about stigmatization may result in seeking treatment for psychic distress by first reporting somatic symptoms to primary medical specialists (Budman et al., 1992; Alem, 1999; Fenta et al., 2004). Political factors, such as immigration status and fear of discrimination, detention or deportation also hinder use of mental health services.
Despite a historical culture of acceptance of religiously and scientifically compatible medical care, modern Muslims abroad and those in the U.S. seem to view mental health interventions with suspicion, or only applicable to problems in Western societies. Many of those who do seek mental health care prefer a counselor with an understanding of Islam (Kelly et al., 1996).
Combined usage of Qur’anic healing and Western psychotherapy is the preferred method of treatment for Muslims (Abu-Ras & Abu-Bader, in press). A major barrier to such a combined method is the preference for Islamic chaplains, who are not trained to act as agents of referral to mental health professionals. Inadequate assessment and inappropriate treatment is often the result of seeking assistance from religious leaders alone (Budman et al., 1992). In general, imams in New York City’s mosques do not know Western psychotherapy techniques (Abu-Ras & Abu-Bader, in press). Imams, themselves, have asked for more contact with mental health professionals in order to provide access to psychosocial services in their communities (Ali et al., 2005). Encouraging collaboration and communication between mental health professionals and Muslim religious leaders has the potential to facilitate proper referrals and improve access to culturally appropriate mental health services.
Some General Guidelines for the assessment and treatment of Muslim patients
Assessment and Consultation
The mental status and physical presentation of an individual depends on gender, age and, importantly, cultural heritage. Rather than assume or generalize, a practitioner should inquire about a patient’s individual customs and preferred practices.
Expressions of symptoms of illness may differ for Muslim Americans from other groups. For example, clinicians should be aware of the presence of visual rather than auditory hallucination in persons with schizophrenia (Bhui et. al., 2001). Different terminology often results in misdiagnosis (Al-Issa, 2000) Dhat, for instance, describes a culture-bound syndrome in which the male is preoccupied with perceived malfunctioning of his genitals; such a condition may be a reflection of some other fear or emotional distress (Mumford, 1996).
Research suggests that psychological testing be conducted in the native language, as cross-cultural validity and false positive diagnoses are possible with tests performed in English on Muslim immigrants (Aposhian, 1995). Inquiry concerning suicidal thoughts must be sensitive to the Muslim patient's belief in God's omnipotence, and may require special phrasing (e.g., 'Have you been wishing that God would allow you to die somehow?').
Muslim clients may require basic explanation about the nature of psychotherapy, the expectations and framework of treatment, and the roles of the provider and the recipient. They may be unaccustomed or uncomfortable with focusing on what appear to be selfish or individualistic concerns and must overcome the barrier of trusting that there will be no reprisal for exposure of one's inner psychic experiences (Erickson & al-Timimi, 2001). The confidential nature of therapy and agreement on protection of information from family members should be discussed because of the Islamic prohibition for expressing negative thoughts or emotions towards one’s family.
The clinician needs to appreciate and educate himself or herself about the social, political and cultural context of Muslim clients, particularly as they relate to issues surrounding relationship preferences and practices, extended family history, and modifications of traditional therapy. Incorporating Islamic beliefs and practices, such as prayer, the importance of the Hadith and the Qur'an, and the communal emphasis in Muslim culture may facilitate therapy (Farooqi, 2006; Hamdan, 2007). Clinicians may encourage the use of resources that have been adapted for Muslim peoples. For example, Millati Islami (The Path of Peace) is a 12-step program adapted for use by Muslims struggling with addictive issues.
The use of medications, in counterpoint to psychotherapy, seems to be better received by Muslims. Abu-Ras & Abu-Bader (in press) found that 80% believe in use of medication for the treatment of mentally ill. The clinician should include explanations for the appropriate use of and expectations for psychotropic medications, particularly for those who have fasting restrictions during and outside of the month of Ramadan or who are making pilgrimage to Mecca for Hajj or Umrah. If a Muslim patient is concerned about the use of alcohol or animal (especially pig) products in medications, they may be referred to their imams who can cite Islamic Law (Shariah) and the Qur'an, which describes that what is typically forbidden (haram) may be lawful (halal) in situations of dire necessity or in order to preserve human life, provided no other options are available (Chaleby, 2001). However, in spite of what may or may not be condoned officially by Islamic Law, the practitioner should be sensitive to the Muslim client's own culturally- and psychologically-informed concerns.
Other considerations should include ethnic and individual variations on absorption, distribution, metabolism or elimination across different ethnic groups. The prescriber might also explore alternative or naturopathic agents, either as part of the patient's routine or used specifically for a particular ailment.
Specific age/gender group problems
Although the Qur'an and Hadith describe men and women as equals, some cultures of Muslim men use self-serving attitudes and ingrained patriarchal belief systems to justify abusing their wives (Haj-Yahia, 2002). By attributing to women sexually provocative behavior or dismissive attitudes towards men, domestic violence is justified (Abu-Ras, 2003). According to Islam, divorce is frowned upon but lawful. In practice, divorce has more negative consequences for women than for men (Watson, 1995). Religion and spirituality play an important role in the way Arab and Muslim individuals, families, and communities cope with their marital problems (Nasser-McMillan, 2003; Abu-Ras, 2007; Al-Banawi, 1995).
Because of language barriers, lack of familiarity, and lack of financial freedom (Abu-Ras, 2003; 2007), Muslim women are likely to seek help from relatives or religious leaders (Hasouneh & Kulwicki, 2007) who encourage tolerance of abuse, citing the greater social value of an intact marriage (Watson, 1995). In therapeutic counseling, the use of Quranic verses, Hadiths, or Islamic laws that discourage violence against women could be effective. Islamic teaching seems to have a positive influence in therapy. When battered women are more aware of their rights, as perceived and written by their own religion, they are more likely to find new ways of protecting themselves, dealing with the abuse, changing their help-seeking behavior, or altering their traditional attitudes toward wife beating (Abu-Ras, 2007).
While Muslim youth may be at higher risk for anxiety and depression (Al-Hinai, 2006), religiosity appears to be a protective factor (Vasegh & Mohammadi, 2007). Studies conclude that religiosity is an important positive factor in negotiating the stress of acculturation (Amer & Hovey, 2007). Religiosity and spirituality are positively associated with adolescent peer group status, academic achievement, emotion regulation, pro-social behavior, and self-esteem, as well as reduced antisocial/problem behavior and internalizing behavior (French, 2008). Religious beliefs and cultural identity among Muslim youth and adolescents may impact the way they address issues of substance use (Marsiglia et al., 2005), immigration (Timimi, 1995), and the need for peer affiliation (Bhui et al., 2005).
While religiosity is a protective factor for mental disturbance, perceived religious discrimination has been shown to influence sub-clinical paranoia in Muslim American youth (Rippy & Newman, 2006).
Family Unit and Elderly
Extended and multi-generational households are common for Muslim Americans. The elderly typically live with their adult children who care for them. The Muslim family provides security and all essential personal, emotional and material support to its members (Al-Haj, 1989; Hassouneh & Kulwicki, 2007; Watson, 1995). Community support, commitment, and sharing of responsibilities and obligations are valued (Abu-Ras, 2003). Members of collectivist cultures depend on each other as well as institutions and organizations for social support, security, safety, and acceptance (Buda & Elsayed-Elkhouly, 1998). When Arab and Muslim immigrants find themselves without such customary support systems, isolation and loneliness can set in. This may impede adjustment to U.S. society, and increase vulnerability to stress or trauma.
Refugees and Victims of Trauma, War and Disaster
Numerous studies indicate that migrants from countries that are politically unstable or culturally different from the host country are more likely to exhibit mental health problems than those from more stable and culturally similar countries (Aroian & Norris, 2003; Khawaja, 2007; Knox & Britt, 2002). Forced migration or trauma, in particular, can lead to significant mental health and social problems (Husain, 2002; Ellis et al., 2008; Jamil et al., 2007; Montgomery & Foldspang, 2008).
In the past 5 to 10 years, several countries with large Muslim populations have experienced man-made or natural disasters. The detrimental social and psychological effects of these events may be particularly felt by Muslims in the U.S. because of their religious affiliation or direct familial connections with the country of origin. Studies show that prior and ongoing exposure to violence can lead to high rates of PTSD, depression, and other mental disorders (Al-Krenawi, 2007; Loncar et. al. 2006; Basoglu et al., 2005; Weine et al., 1995; Fenta et. al., 2004; Thienkrua, et. al., 2006; Najam, et al., 2006).
Terrorist attacks in the U.S. and abroad seem to re-traumatize refugees from war-torn areas. Bereavement responses among Muslims faced with traumatic life circumstances can vary. After the Hebron massacre, Muslim Americans reported “accepting the ultimate decisions of God” (Al-Krenawi, 2001-2002). In reference to the London train bombings, Rubin et al. (2005) found that “being Muslim was associated with a greater presence of substantial stress,” but no “widespread desire for professional counseling”.
The tragic events of September 11th, 2001 have emotionally affected all Americans, especially Muslim-Americans directly and indirectly, acutely and chronically. Following 9/11, Arab- and Muslim-Americans were exposed to heightened levels of discrimination, suspicion, hostility, and hate crimes (Abu-Ras & Abu-Bader, in press). Consequently, clinically significant depression, anxiety, fear, and psychological problems increased in the Arab- and Muslim-American communities (Abu-Ras & Abu-Bader, in press; Moradi & Hasan, 2004; Stodolska & Livengood, 2006).
Post-9/11 discrimination and hostility acted as acute stressors for development of depression and PTSD (Abu-Ras & Abu-Bader, in press). Those Muslim-Americans for whom the trauma of 9/11 revived memories and experiences of earlier trauma, reported intensified experiences of discrimination and exacerbated political, economic, social, spiritual, psychological and medical challenges (Abu-Ras & Abu-Bader, in press).
Osman Ali, MD.,
Clinical Assistant Professor, NYU-Bellevue
Private Practice, New York City
Wahiba Abu-Ras, Ph.D.,
Assistant Professor, Adelphi University
Hamada Hamid, DO, MPH,
Neurology Fellow, Yale University
© 2009, OMH
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