Perceptions from the British Pakistani Muslim community towards mental health

ABSTRACT

Mental health issues are worldwide, impacting people from all backgrounds, ethnicities, and religious denominations. The current study aims to explore the perceptions of the British Pakistani Muslim community towards mental health and barriers towards seeking treatment. Semi-structured interviews with seven Muslim participants of Pakistani origin (four female) explore how they perceive and understand mental health in the Muslim community. Reflexive thematic analysis identified four themes: (a) culture vs religion, (b) religion as a protective factor, (c) fear of public opinion, and (d) integration of religious and professional services. Participants discussed a negative cultural perception and positive religious perception towards mental health. Services that integrate both a religious and western psychological model to effectively treat mental health issues are suggested. The results indicate towards a tailored framework to tackle mental health and can be used in addressing issues and concerns of the Muslim community concerning mental health.

KEYWORDS:

• Mental health
• perceptions
• Muslims
• mental health treatment
• religion

Introduction

The consideration of mental health for individuals of all communities and backgrounds including people from minority communities is important in effectively tackling mental health illnesses. The lack of research exploring how the Muslim community perceive and understand mental health calls for research in this area. A survey of 1071 Muslims between the ages of 16–30 years reported a variety of mental health illnesses, including suicidal ideation (32%), anxiety (63%), and depression (52%) (Muslim Youth Helpline, 2019). Despite this, a large proportion would choose not to seek help for mental health support. As such, it is important to explore factors that influence mental health, and reasons why people choose not to seek help for mental health issues.

Noubani et al. (2020) conducted a study exploring mental health and mental health services using semi-structured interviews with 89 participants from Syrian and Lebanese refugees in the areas of Beirut and Beqaa. The research highlighted social constructs, political conflicts, and financial difficulties as potential risk factors in mental health. Gender issues and integration challenges were also raised as conceivable influences for poor mental health, so there is a need to further explore mental health support. However, research has identified barriers to mental health treatment. Inayat (2007) looked at the barriers Muslims faced in seeking help for mental health, identifying language barriers, discrimination, racism, cultural differences, religious issues, and fear of treatment acting as barriers to mental health support. These barriers also extend beyond the Muslim community. For example, Salaheddin and Mason (2016) in a study of 201 18–25-year-olds in the UK found that 35% of participants did not seek mental health treatment. Qualitative responses showed negative stigmas attached to poor mental health, inabilities in articulating mental health difficulties, and self-reliance and struggles in accessing appropriate help as predominant barriers to mental health support. These barriers to mental health services for treatment and preventative measures indicate a need to further explore perceptions towards mental health, particularly from the Muslim community.

The stigma towards mental health can have an array of physical, psychological, and emotional consequences for individuals that require mental health treatment (Happell et al., 2012; Henderson et al., 2014). It is this stigma that can act as a barrier for individuals seeking treatment from providers (Corrigan et al., 2014; Weatherhead & Daiches, 2010). For example, Sickel et al. (2019) reported that stigma towards mental health predicted negative attitudes towards seeking treatment, with individuals reporting higher levels of anxiety and lower levels of general self-efficacy when mental health stigma was more severe. Research has also considered the views of mental health professionals and their experience of providing counselling services. For instance, Saleem and Martin (2018) explored professionals’ experience of providing mental health services to Muslim women and found that difficulty of seeking help and lack of awareness were key barriers to mental health treatment. In particular, the findings suggested cultural restrictions act as a barrier for Muslim women to seek help due to traditional family and gender roles, and fear of consequences for seeking counselling services. It is important to further explore the barriers to seeking mental health treatment in the Muslim community. The current study explores the perception towards mental health and the role of stigma towards mental health treatment from the Muslim community.

Islam, the religion of Muslims, has established clear guidelines in the preservation of mental health of both an external nature (e.g., acts of worship, establishing good relationships, cleanliness, and eating) and internal nature (e.g., keeping good intentions, reasoning deduced from the revelation of the Qur’an and knowledge of oneself and of God) (Haque, 2004). These religious guidelines are important in promoting mental health and can act as a protective factor against suicide (Brenner et al., 2009). The notion that religion can act as a protective factor to mental health problems is further supported in the literature. For example, Sharma et al. (2017) examined the role of religion and spirituality towards mental health outcomes using a sample of 3151 military veterans from the United States. The results suggest a protective association between religion/spirituality and mental health, with religion seen as a protective factor in preserving good mental health. In addition, religion was sought out in times of difficulty when poor mental health may be experienced. Furthermore, the results showed that high religion/spirituality was associated with decreased risk for depression, alcohol use, and post-traumatic stress disorder (Sharma et al., 2017). Ano and Vasconcelles (2005) highlighted a positive association between positive religious coping and good mental health. In addition, Muslims that have a religious affiliation compared to those that do not report higher levels of happiness and satisfaction with life (Koenig & Al Shohaib, 2017). This suggests that promoting religion/spirituality is an important endeavour to increase purpose in life, and reduce mental health outcomes (e.g., lifetime depression, suicidal ideation, etc.).

Similar findings have also been presented with specific religious acts of worship as practiced within the religion of Islam being associated with enhanced well-being and good mental health. Koenig and Al Shohaib (2019) conducted a systematic review investigating the relationship between religiosity and mental health in Muslims. Results indicated towards engagement in acts of worship such as reciting the Qur’an and adherence to its teachings, prayer and being devout Muslims leading towards having good mental health. The results may help mental health professionals in understanding of symptoms presented by Muslim patients alongside effective intervention techniques designed to aid Muslims in treatment of mental health illnesses. The exploration of the role of religion in preserving mental health issues is an important factor to aid in the understanding of what measures can be put into place to effectively treat mental health issues.

The seeking of help by Muslims from religious professionals in safeguarding and preserving mental health has also been detailed in literature (Dein et al., 2008; Khalifa et al., 2011). Dein et al. (2008) reported regular assistance of religious practitioners in healing physical and mental health illnesses. It was observed that this was when witchcraft or jinn possession was said to be involved and a belief that it was causing the affliction being experienced by individuals. The belief of negative effects on mental health and harms caused by the possession of spirits has also been reiterated in previous studies with particular reference to South Asian Muslims (Dein & Illaiee, 2013; Gaw, 1993). It is important to conduct further studies to explore the potential risk factors of poor mental health and whether there is a common belief held in jinn possession and its effect on mental health by sub sections of the South Asian Muslim community in gaining a better understanding.

Differences in attitudes towards genders has also been seen to affect mental health negatively with increased risks in developing mental health illnesses such as depression for Muslim women (Laher et al., 2018; Malhotra & Shah, 2015; Walpole et al., 2013). Laher and colleagues (2018) carried out a mixed methods study investigating the understanding around major depressive disorder. 12 female participants took part in the qualitative research data collection and 62 female participants took part in the quantitative research data collection. All participants were of South African Indian Muslim background. Results indicated gender inequity as a perceived causal factor in the development of major depressive disorder whilst religion was perceived to have no effect on its development. Further study of the aetiology of mental health illnesses using perceptions from the Muslim community within the UK may provide insight into gendered perceptions and whether similar views may be held in Muslim communities across different countries.

In summary, while the increasing rates of mental health outcomes amongst the Muslim community have been acknowledged, research suggests a large majority of individuals will choose not seek help for mental health illnesses (Muslim Youth Helpline, 2019; Noubani et al., 2020; Salaheddin & Mason, 2016). Exploring factors that may contribute to individuals not seeking mental health treatment, a variety of perceived barriers have been identified (e.g., negative stigma towards mental health treatment, accessibility, etc.) which require further exploration to further understand perceptions of the Muslim community towards mental health (Inayat, 2007; Saleem & Martin, 2018; Weatherhead & Daiches, 2010).

The aim of this study is to explore how the Muslim community perceive and understand mental health and mental health treatment.

Method

Participants

Participants were recruited from a Muslim community organisation in England, United Kingdom. Seven participants took part in the interviews, which included four females and three males. The sample size was identified as appropriate and in line with previous recommendations (Braun & Clarke, 2013), and was expected to be sufficient for saturation. Participants identified as having Pakistani ethnic roots with all participants born in England, United Kingdom, and residing as British Nationals. Participants were aged between 20 and 40 years of age. All participants identified as having received some level of education from undergraduate to postgraduate studies within the United Kingdom. All participants identified as having affiliations and links to the Sunni Muslim community.

Procedure

The local Ethics Committee approved this study. A Muslim community organisation based in England, United Kingdom was contacted for the recruitment of participants via email. The organisation is based in an urban area within the Midlands, England, with an outreach across the United Kingdom. The interviews were conducted online via Microsoft Teams. Participants were informed about the nature of the research and all participants provided informed consent. The interviews were conducted following a semi-structured interview guide informed by prior literature on mental health communities as outlined in the Introduction (Koenig & Al Shohaib, 2017; Noubani et al., 2020; Salaheddin & Mason, 2016; Saleem & Martin, 2018). For example, prompt questions included “How do you think mental health should be defined?”, “What factors do you think influence mental health?”, “What barriers do you think there are in seeking help for mental health within the Muslim community?”, and “What should be done to promote mental health awareness within the Muslim community?” (see Appendix). All interviews were audio recorded, transcribed verbatim, and lasted approximately 30–45 min.

Data analysis

An inductive reflexive thematic analysis was conducted to understand and explore the data (Braun & Clarke, 2006; 2019). Mental health and mental health treatment can be personal and sensitive to the individual, interviews provided a more accurate reflection on how mental health is perceived, and barriers to seeking treatment. The interviews were audio recorded and transcribed verbatim. The analysis was conducted by one coder, an approved practice for reflective thematic analysis (Braun & Clarke, 2019). The procedural position of the analysis was reflexive to embrace the value and subjective skill of the coder. This position allowed for an open and organic coding procedure and as such the focus on reliability and inter-rater agreement is not appropriate. This has been advocated by Braun and Clarke (2021). The reflexive thematic analysis conducted provided a systematic interpretation of the data to identify a pattern of shared meaning across the interviews (Braun & Clarke, 2019). The transcripts were read and re-read to allow for familiarisation. During familiarisation, initial notes were made on the transcripts. Following familiarisation, the transcripts were reviewed and coded several times to ensure the views of participants had been fully explored and coded appropriately. The codes were reviewed across each transcript and collated into categories. These categories were then reviewed and collated across the data set. Themes were then identified. The themes were named, defined, and a comprehensive report was produced analysing the themes alongside the extracts from the data set to support notions provided (Braun & Clarke, 2006; 2019).

Results

Four themes were identified from the reflexive thematic analysis: (a) culture vs religion, (b) religion as a protective factor, (c) fear of public opinion, and (d) integration of religious and professional services. Table 1 provides a summary of the themes and associated subthemes. All participants illustrated each theme.

Table 1. Summary of the themes and subthemes.

Themes	Subthemes	Example
Culture vs religion		I think culture plays a big part in kind of receiving mental health because people just don’t understand it. They just think all it might just be black magic that someone is doing on them or again what I said earlier about not being a good Muslim or don’t pray or something. They might say that and because it’s just not understood (Zahra)
Religion as a protective factor		I feel that religion gives hope and I feel like that’s why people would turn to religion errm because it’s the thing that has been there for centuries so and so has this mental health or this depression or stuff like that so it’s been there just as long so I feel like religion is seen as way of life, a way of living on how to live and how one should live (Uthman)
Fear of public opinion	Mental health as non-existent	Mental health in today’s day and age, I think it’s, no one takes it seriously to be fair, in the Muslim Pakistani community, if someone comes out with they have got some sort of illness like their head is hurting or they have depression, everyone will laugh it off thinking you know what, you are just having a joke, you are just having a laugh. And no one takes its seriously, it’s just like something is brushed under the carpet (Rashid)
Integration of religious and professional services		would like to see that these services are used by Muslims and I think if these services do put in place those who have a better understanding of the religion, I think the patients will be more understanding to open up about their problems and take the steps needed. (Nafisah)

Theme 1: Culture vs religion

The first theme was built upon the experiences and feelings of people who perceived religion as being misconstrued as culture. References to culture playing a negative role in the maintenance of mental health with cultural practices often disguised as religion were presented and mentioned:

I think then culture comes into play and they kind of make it out to be like a weakness maybe in people that are suffering from mental illness, I don’t think it’s the religion. I think religion sometimes does play a tiny bit of a part but mainly culture. (Zahra, age 22)

The association of cultural practices and beliefs being misconstrued as religion suggest the negative implications associated with beliefs in relation to mental health from a religious perspective. Zahra highlights how a lack of religiosity can be wrongly determined as a factor in having poor mental health with a strong indication towards cultural influences as potential risk factor instead. The same sentiments were presented by other participants who also voiced the role of familial relationships in presenting cultural norms and beliefs:

OK I think a lot the two biggest factors are culture and family because I feel like your family like how they react to like your attitude and stuff that affect how you are. I feel like family attitudes like some people are not close to their family and so their mental health might get worse. Because I have no one to speak to and I feel like culture is like my parents. I don’t think they know what anxiety is. They know what the depression is, but I feel like a lot of the mental health problems, they don’t know what they are … (Hafsah, age 19)

Hafsah paints a picture in which culture is denoted as one of the two biggest influencers of mental health. She recognises and highlights the complex interplay between culture and family attitudes and how it can lead to specific views on mental health. For instance, while adults may be recognised as having poor mental health, children are not considered as susceptible to poor mental health but rather a lack of religiosity. The possibility of lack of knowledge surrounding different mental health problems within cultures is also raised as a potential reason for attitudes held towards the existence and treatment of mental health problems. Culture can also play a central role in the development of mental health issues with specific cultural practices which highlight gender inequality as a norm negatively influencing the mental health of Muslims, particularly females:

Not religion specifically but culture with people that are Muslims and stuff. Errm, I think that does affect people with their mental health … . Well culture like, I’m Pakistani, and obviously with our culture boys are treated differently than girls and obviously that can affect some girls’ mental health especially if they are getting treated differently. Their parents being more strict on them just because they are a girl … (Raaniyah, age 21)

Raaniyah also voices a similar issue of the negative implications of cultural practices and beliefs in gender inequality within family settings. Her statement shows the consequences of such discrimination and how it can impact the mental health of individuals with reference to females as opposed to males. The statement starts with a clarification (e.g., “Not religion specifically but culture.”) that culture, as opposed to religion, affects mental health with Raaniya providing details on cultural practices that lead to poor mental health.

These accounts suggest that participants perceive culture being disguised as religion in influencing mental health in a negative manner. These discourses provide an insight into how cultural beliefs can associate lack of religiosity with poor mental health with Muslims highlighting the harmful impact of such ideologies; stressing that it is not religion but culture that should be associated with poor mental health. The two opposing beliefs bring the differences in older and younger generations within the Muslim community with regards to mental health to attention; the older generation believing a lack of religion impacts mental health with potential disregard to other influences and the younger generation believing cultural influences as a possible reason for poor mental health over religion.

Theme 2: Religion as a protective factor

The second theme looked at the beliefs of Islam and how people relate and turn to Islamic acts of worship to draw strength in times of poor mental health. Concepts around religion were discussed with perceptions that Islam represents hope and is a protective factor in maintaining good mental health. Participants voiced the encouragement that they felt came from the religion of Islam in maintaining good mental health and seeking help where necessary with the Qur’an referenced as a source of understanding mental health:

So, I think, Islam for example, is errm quite clear that everybody, you know, just because you are Muslim, doesn’t mean you won’t encounter certain things in life which will make you feel low or maybe anxious or maybe depressed but this is part and parcel of life. However, having for example the Qur’an, err being able to read through it or understand what it actually means, you may have a better understanding of this and that religion pushes you to go and seek help. Religion teaches you that seek Allah’s help and also seek what’s out there for you. These tools are being put out there for you to help you overcome any situations that come your way. (Nafisah, age 38)

Nafisah’s feelings portray a strong sense of belonging to the religion of Islam and the impact it has in safeguarding the mental health of individuals who identify as Muslim. Her account captures the essence of what being a Muslim entail and the holistic perspective with which Islam actively encourages seeking professional help alongside engaging in acts of worship specific to Islam. For example, reading the Holy Book, the Qur’an, offering five daily prayers and invoking Allah as a means of alleviation from poor mental health. Her statement “ … just because you are Muslim, doesn’t mean you won’t encounter certain things in life which will make you feel low or maybe anxious or maybe depressed but this is part and parcel of life … ” also highlights how belonging to a specific religion does not provide immunity to mental health problems; rather it brings an awareness that everyone is susceptible to mental health problems which can then be treated through a variety of means, including turning to God. The strong sense of belonging and the positive energy gained by acts of worship specific to Islam as mentioned, highlights a trend specific to Muslims in viewing religion to safeguard mental health and increase a good state of mind. The positive concept of religion is also discussed in other accounts:

 … people need aspirations, they need goals, a sense of achievement, people need senses of motivation that they need, and this comes with religion and with recitation of Qur’an. It comes with your five daily prayers, anticipating the next prayer, wanting to communicate with the Creator. This is a huge sense of belonging you know and that is what religion provides. (Mehmet, age 41)

The account by Mehmet portray religion as a positive concept to identify oneself with through which acts of worship, specifically Islamic acts of worship, are associated with motivation, belonging and positivity, all factors which promote good mental health. Mehmet expresses having good mental health is achieved by virtue of needs being met. The extracts suggest that a lack of aspirations and goals, whether on a personal or professional level, could possibly influence mental health negatively: “people need aspirations, they need goals, a sense of achievement, people need senses of motivation … ”. He voices that consequence of such needs being unmet, which include belonging to a religion, are the effects of having negative thoughts and feelings which may contribute to poor mental health. In addition to acts of worship associated with Islam (e.g., daily prayers, worshipping God, reciting the Qur’an), suggested as positive contributors to good mental health, reflection upon verses of the Qur’an specific to mental health is also voiced as a self-help measure in improving poor mental health. The extent to which Islam promotes mental health was also discussed:

 … I’ve seen, like quotes. I feel like if I felt like down that day like I don’t have any mental problems, but certain quotes. I feel like some people who are depressed when they see quotes or like listen to either the Qur’an they feel more like, ‘yeah, I have hope.’ The one that says God does not burden a soul more than it can bear, I feel like that pushes a lot of people. (Hafsah, age 19)

Hafsah’s response explores conviction in the effect of religious quotes or verses from the Qur’an which instil a sense of hope and raise morale of individuals who may have feelings that induce low spirits or poor mental health. She supports the views of other participants who also voiced turning to the Qur’an as a form of support in times of mental health fatigue. Turning to the Qur’an is described in one of three ways throughout extracts from participants: reciting the Qur’an, listening to the Qur’an, or reflecting upon the verses of the Qur’an. This gives a clear insight into the integral role the Qur’an plays in the life of Muslims and how it is regarded as a protective factor in maintaining good mental health. The positive role of religion is further highlighted:

 … Islam promotes mental health. There’s ways Islam tries helping people, and there’s always people in Islam that are willing to help like for example in the mosque, the Imams and stuff, they’re always willing to give time to their people, their congregation and speak to them. (Rashid, age 26)

Rashid further expands on ways Islam promotes mental health by way of religious leaders from whom people, who may be experiencing mental health issues, can approach and talk to them as a form of support. He mentions specific settings in which Muslims can access support and help which is in line with Islamic traditional teachings whilst also highlighting a solution for mental health issues associated with the arrangement of time and its availability for people to talk about struggles as an effective measure in dealing with poor mental health. However, it is shown that despite encouragement from Islam in seeking out religious leaders to treat poor mental health, Muslims may not always actively seek out help for mental health in the form of talking about issues that may be affecting them:

I think probably it’s not really a Muslim thing, probably more of a culture thing. Again, where kind of it’s like a pride thing. You don’t want to get help because you think it’s gonna make you like a weak person. I think especially for a man it probably a bit more difficult for them ‘cause they should always be seen as like the strong person and they kind of need to always be strong. (Zahra, age 22)

Whilst there is a sense of acknowledgement of turning to religious leaders, multiple accounts from participants also highlighted how there is a difficulty associated with seeking help from professional services, religious leaders or family and friends. Societal expectations in which a certain image is created to be maintained and upheld can become a hindrance as explored and voiced by Zahra. Specifically, perceived weakness acting as a barrier to seeking mental health treatment may further prolong lifetime mental health consequences. Narratives on religion as a protective factor bring an awareness to the role religion can play in preserving mental health and the potential it has in treating poor mental health. Participants share feelings on different ways the religion of Islam provides solutions in maintaining good mental health. For instance, the spiritual awareness in reflection upon verses from the Qur’an, Islamic quotes as a medium of physically seeking help, and speaking to religious leaders who can help and support.

Theme 3: Fear of public opinion

Fear of public opinion describes the barriers to seeking help for mental health due to discrimination and stigma. Societal pressures of public image are voiced as instrumental through accounts of individuals who explore possible barriers to accessing treatment for mental health problems. Perceptions from an external perspective highlight how a perceived image of what a Muslim should do and religious obligations being unmet may act as a potential barrier in seeking treatment due to not wanting to be portrayed as something other than the ideal Muslim:

They probably feel embarrassed and feel like they are going to be judged. Errm, they probably want to talk about their sins and stuff which probably affects their mental health especially, they going to feel guilty and stuff and obviously they’re going to have no one to talk to so they’re probably just going to feel like they’re going to be judged and not want to talk about it at all which obviously makes it worse. (Hawaa, age 20)

Hawaa’s account explores potential reasons as to why help may not be sought by individuals with mental health difficulties. For example, the internal conflict an individual may experience: the embarrassment which may be felt at disclosing situations which are labelled as sin in accordance with the religion of Islam. This paints a narrative in which expectations of the religion of Islam that may not be fulfilled, and so feelings of guilt may contribute to poor mental health. In addition, issues with disclosure and seeking mental health treatment. The perceived judgement and labelling of individuals seeking mental health treatment suggests an internal conflict of wanting to seek help, but also a barrier in doing so. The impact and stigma of religiosity is also discussed:

Muslims going through that, they may not want talk to anyone about it only because of the stigma is his belief in Islam strong enough, why isn’t is strong enough, and I think when you know you may get questions based on your level of belief, that’s not really answering anything and that’s where people be like “Oh, that’s not something I want to deal with at the moment. I don’t want to add another burden onto what I am already going through at the moment.” (Uthman, age 27)

A stigma surrounding religiosity and lack of mental health is presented as a barrier to seeking mental health treatment. Uthman suggests the impact of stigmas result in an extra “burden” on top of other mental health issues. He describes the labelling of a lack of religiosity for people with mental health issues as a situation that individuals may not be able to deal with or accept, implying the seriousness of the place with which the religion of Islam is held for Muslims. Anything that could be interpreted in a manner which disassociates a Muslim individual from the religion could have catastrophic consequences, a situation which is seemingly not ready to be accepted. This fear of public opinion regarding religiosity portrays the sensitivity in which Muslims hold their faith and how certain religious ideals (e.g., attire, forms of worship) are important in the life of a Muslim. However, the perceived need to be accepted by society, particularly with concepts that include and endorse Islamic beliefs, may impact on mental health. The fear associated with a lack of religiosity is also discussed as why treatment may not be sought:

 … like I feel like some people will just think they would just say pray or like they wouldn’t try to get to the cause of the problem, or they would say the faults of the person rather than to be like they would like say is someone something haram and something I don’t know, it’s obvious that they’re not like very religious … (Hafsah, age 19)

Hafsah, in her exploration of why treatment is not sought out by individuals from the Muslim community for mental health issues, also attributes a fear of public opinion regarding lack of religiosity. She expresses apprehension in the treatment that may be offered because of mental distress with solutions focused on engaging in Islamic acts of worship. Hafsah notes that this is detrimental, and the root cause/s of mental health issues lie undetected and not explored fully to find proactive solutions in managing mental health. Hafsah suggests the negative stigma and stereotypes attached to seeking help for mental health treatment in the Muslim community acts as a barrier to mental health treatment (e.g., “ … is someone something haram … ”). The word haram is denoted as an act which is forbidden within the boundaries of Islam, a word used by Hafsah to explain why individuals may be discouraged in seeking help as they do not want to be labelled as individuals who are seen as unreligious, a sentiment shared by many of the participants in the study.

Mental health as non-existent

A sub-theme of “fear of public opinion”, extends the narrative further by looking at the consequences associated with and as a result of public opinions on mental health from an external perspective. Accounts describe the non-acknowledgement of symptoms that are presented as mental health issues in relation to children and from a cultural perspective that is portrayed as religion:

 … this girl I know, obviously I did Psychology I saw I her have a panic attack and I know what it looks like because I have seen other people have it and they were just saying like she’s like crazy and it’s just in her head. I was like so your culture like some people just see it like crazy they don’t define it as mental health illness that needs to be treated. They justify it as something that is like and they have like the cultural stigma against it and like I think it’s not taken as seriously in some cultures compared to others … (Hafsah, age 19)

Personal experiences with mental health show narratives in which symptoms that are associated with mental health problems are not acknowledged or instead being depicted in a derogatory manner within certain cultures. Hafsah shares a personal account in which individuals responded in a negative manner labelling the person with a damaging stigma as opposed to highlighting the issues at hand and seeking treatment. This suggests a possible lack of education surrounding mental health issues and the lack of seriousness taken regarding it and the implications it can have on individuals. Mehmet also provides an account highlighting the perceptions of specific communities, namely South Asians as negatively viewing mental health:

So, for example, you have the Indian sub-continent community perception of mental health which doesn’t allow young people to express themselves. So, it’s looked down upon. It’s seen as, not an illness, but as a plague. It’s looked down upon. It’s looked as an outcast of society, it’s looked as if a person suffering from mental health is a demon, okay? So, these, ah, are things ingrained upon. So as kids, when you walk past, or drive past an institute that specifically deals with mental health issues, people will point or mock that particular hospital. ‘This is where all mad people go, this is where crazy people go.’ (Mehmet, age 41)

He openly describes the treatment given to people with mental health issues with individuals regarded as outcasts and an ingrained concept of abnormality associated with mental health issues. The derogatory terms associated with mental health (e.g., “person suffering from mental health is a demon”) that are used in society influence the understanding around mental health issues and can lead to the inhibition of seeking mental health treatment.

Theme 4: Integration of religious and professional services

Integration of religious and professional services portrays ideas around the combination of an Islamic-oriented framework integrated with professional services available. A desire to adapt services available to provide a tailor-made approach in treating mental health issues that individuals from the Muslim community may be dealing with is voiced and shared by participants who all share the sentiment, the usage of religion plays a role in the treatment of mental health issues:

 … We need to see it not only from a medicinal perspective, but also from a spiritual perspective. So, yes we need more Imams, more religious people that are specialists in mental health issues because that is very very important … (Mehmet, age 41)

The mention of religious practices as part of a holistic approach in treating mental health issues show the importance with which Muslims perceive and hold the religion of Islam. Mehmet mentions the need for a change in the perspective of how mental health is managed to include a holistic view of which religion is a component. The training of religious leaders in mental health is suggested to Muslims who may be suffering from mental health issues. This highlights the avenues that Muslims may seek in the treatment of poor mental health and a potential gap in receiving the best care in managing mental health. In addition, religious teachings are discussed as a fundamental role:

It’s kind of like finding a balance of both of them so. Yeah, you need to have someone with Islamic knowledge and then also the psychological knowledge because they kind of pick bits out that are useful for you. (Raaniyah, age 21)

Raaniyah’s account reiterates the position of Mehmet in the acknowledgement of religious teachings playing a fundamental role in the treatment of mental health. She encourages an integration in psychological knowledge and teachings with a religious underpinning taken from the religion of Islam as a route that provide services for Muslims within the community who experience mental health issues. The need to have a tailored service is also acknowledged:

 … an organisation, run solely by errm religious and psychiatrist specialists., I am saying they need to have a good amount of knowledge of Islam and err a very very good knowledge of the psychiatry side of it. (Uthman, age 27)

Uthman, as the other participants, provides an insight for having a tailored service consisting of religious leaders and professionals in dealing with mental health services. His usage of the word “need” holds a sense of urgency in which no other option is presented as viable in the treatment of mental health issues for Muslims in the community. Narratives around integration of religious and professional services capture a gap in treatment services available for mental health issues regarding the Muslim community. It highlights the necessity of the merging of different services namely religious institutes and healthcare professionals in determining the best course of action to deal with growing cases of mental ill health and providing a service tailored to meet the needs of a minority community.

Discussion

Four themes were identified across the interviews: (a) culture vs religion, (b) religion as a protective factor, (c) fear of public opinion, and (d) integration of religious and professional services. The themes provided a rich insight into the perceptions and understanding surrounding mental health from individuals from the Muslim community.

In the theme of culture vs religion, participants perceived religion being misrepresented as an influence leading to negative perceptions around mental health. Findings suggest a negative cultural bias in the perception of mental health over religion with culture often obscured and presented as religion. In the religion as a protective factor theme, participants perceived that religion had a positive influence in minimising potential risks to poor mental health. Compared to culture, religion was perceived as a protective factor to poor mental health due to the faith and belief in God.

Regarding the theme fear of public opinion, findings suggested discrimination and stigma associated with seeking mental health treatment acting as barriers for the Muslim community. This fear of public opinion was also attributed in explaining why mental health is not acknowledged within the Muslim community. As a direct consequence of this fear of public opinion, participants perceived that mental health is instead treated as non-existent, with symptoms presented defined as being mad or crazy. In the integration of religious and professional services theme, participants suggested integrating traditional religious teachings with mental health services as a solution to promote mental health and well-being. The integration of religious and professional services is suggested as a solution to encourage mental health treatment within the Muslim community. Specifically, the integration of religious and professional services highlights a need to train religious leaders to encourage dialogue with religious and psychological knowledge to encourage disclosure of mental health illness.

The findings are consistent with previous research exploring the barriers to seeking mental health treatment (Corrigan et al., 2014; Inayat, 2007; Salaheddin & Mason, 2016; Sickel et al., 2019). Specific to the current study, findings suggested that discrimination, cultural issues, language barriers and negative stigmas associated with mental health act as barriers for the Muslim community in seeking mental health treatment. The findings reflect previous qualitative research suggesting that social constructs and gender roles can influence poor mental health (Malhotra & Shah, 2015; Noubani et al., 2020). The study also highlights a viewpoint from a male perception in the lack of diagnosis and seeking of assistance for mental health illnesses due to fear of a lack of social reputation. This suggests that whilst females may voice mental health issues due to gender inequality, undetected cases from the male population due to stigmas may be limiting what perceptions are being formed around the aetiology of mental health illnesses from a gendered perspective. McKenzie et al. (2018) highlighted similar results in observing male practices in accessing support services for mental health.

The findings suggested that culture can be portrayed as religion to influence negative stigmas towards the diagnosis, seeking of treatment and management of mental health issues. In particular, the notion of culture and religion is often intertwined, especially within the older generations of the Muslim community highlighting a difference in the understanding towards mental health and social constructs between the elder and younger generation which could exacerbate mental health symptoms further. The finding that religion acted as a protective factor to mental health (e.g., turning to the faith Islam as a means of treatment), is also reported in previous literature highlighting the protective role of religion in the context of mental health (Brenner et al., 2009; Dein et al., 2008; Dein & Illaiee, 2013; Sharma et al., 2017). Seeking of help from religious practitioners was a theme that continued to be reiterated throughout the interviews, a viewpoint that is consistently highlighted in previous literature (Dein et al., 2008; Khalifa et al., 2011). This adds to the element of religion as a protective factor with religious professionals possibly serving as a middle ground in being able to provide individuals with a greater understanding of religion as a tool to effectively manage mental health illnesses. Furthermore, the mention of specific religious practices related to the religion of Islam such as prayer, reciting of Qur’an and reflection were also highlighted as tools used to regulate emotions and lessen symptoms of poor mental health which was reflected in previous research (Koenig & Shohaib, 2019). In addition, the findings suggested a need to integrate traditional Islamic frameworks with psychological services in treating mental health. Discourse around educating religious leaders, the Muslim community, and an increase in therapists and mental health specialists were also emphasised to effectively address mental health issues within the Muslim community.

Limitations and practical implications

Some limitations of the study need to be noted. Firstly, the self-selecting nature of participation may present bias in participants’ accounts towards how they perceive mental health. On the one hand, this may mean individuals from the Muslim community that have an interest or role in addressing mental health are more likely to volunteer. On the other hand, individuals from the Muslim community may have volunteered to participate on the basis to acquire more knowledge on mental health treatment. Therefore, it is important to note that other views from the Muslim community may be different to that presented in the current study. While the sample is limited, the findings are not intended to apply to all British Pakistani Muslims. Across all participants the same ideas and issues were being discussed. Future research should endeavour to build on the current study and explore different issues associated with mental health in the British Pakistani Muslim community. Despite these limitations, the current study offered a unique insight to the voices of those in the Muslim community to explore how they perceive and understand mental health. One line of argument proposed by Lincoln and Guba (1985) is that research needs to be strengthened by its trustworthiness. This approach involves establishing credibility (i.e., confidence in findings), transferability (i.e., how the findings are applicable to other contexts), dependability (i.e., are the findings consistent), and confirmability (i.e., how the findings are shaped by the respondents and not research bias). Such approach would endorse the inter-coder agreement, reliability, and validity on themes within qualitative research. The approach taken in the current study was a reflexive thematic analysis (Braun & Clarke, 2006; Braun & Clarke, 2019), which does not advocate such approaches proposed by Lincoln and Guba. The reflexive thematic analysis undertaken values the subjective skills the researcher brings to the analysis by fully embracing qualitative research.

The views from the Muslim community presented in the current study offer some important practical implications for mental health treatment. The findings can be used to inform practices in developing specialist frameworks devised in conjunction with Muslim authorities and leading figures for mental health treatment. For example, integrating Islamic traditional practices with psychological services would encourage Muslims to disclose mental health problems and seek treatment. The findings also suggest a need to reduce discrimination and negative stigma towards the Muslim community regarding mental health treatment. To do this, Muslim authorities and/or organisations need to encourage open conversations about mental health within the community. One solution can be to implement mental health awareness workshops to educate individuals on the impact of mental health, and the importance to seek out mental health treatment if needed. Such approaches could incorporate posters, cooperative group work, and dedicated talks to get everyone involved to talk about mental health more. These initiatives would be best facilitated via direct contact with the community, as direct contact has been reported to be the most effective method by which to improve awareness, social distance, and change attitudes (Yamaguchi et al., 2011). The rolling out of such programmes may be extended to places within the community that are most accessible to Muslims (e.g., mosques and community centres). The implications of the results also suggests that mental health practitioners should strongly consider the role of religion as a resource to address mental health issues. For example, mental health practitioners should provide a safe and welcoming space for Muslims to discuss their mental health issues and religious beliefs in a supportive environment and consider integrated therapy/treatment if they have a strong religious belief (Koenig & Al Shohaib, 2017).

In summary, the findings highlight the role of religion and culture within the Muslim community on how individuals perceive and understand mental health. Participants discussed a negative cultural perception and positive religious perception towards mental health. Importantly, religion was perceived as a protective factor for mental health, which should be considered when integrating Islamic religious services and professional services as a solution to mental health treatment. The findings also suggest a need to reduce discrimination and negative stigma towards the Muslim community regarding mental health treatment. The findings suggest a need to foster mental health awareness within the Muslim community to encourage mental health treatment.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Appendix

Semi-structured interview guide

How do you think mental health should be defined?

What factors do you think influence mental health? Why?

What do you think about seeking help for mental health?

What barriers do you think there are in seeking help for mental health within the Muslim community?

What do you think are stigmas associated with mental health within the Muslim community?

What should be done to promote mental health awareness within the Muslim community?