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British Muslims habitually respond to the onset of mental illhealth by turning to their faith leaders. How Muslim faith leaders manage these encounters remains largely unexplored. In this study, 41 Muslim religious leaders in the UK completed vignettebased surveys depicting an individual meeting DSMIV criteria for depression or schizophrenia. Participants were questioned regarding beliefs about etiology and treatment, counseling training and activity, and referral behavior; stigma levels were also measured. Muslim faith leaders were found to exhibit low stigma, provide substantial informal counseling, and routinely refer individuals to mainstream mental health services. They simultaneously embraced environ24 Sazan Meran and Oliver Mason mental, biological, and religious causes for mental illness. Muslim faith leaders emerge as potential allies in efforts to improve mental health outcomes for British Muslims, by challenging community stigma and collaborating with mental health professionals to deliver holistic care. In 2005, the U.K. Department of Health published an action plan for delivering race equality in mental health care and found a significant need to provide culturally appropriate services to individuals from ethnic minorities, as well as address high levels of distrust of mental health professionals among these groups (Department of Health, 2005). With an estimated population of 2.7 million, British Muslims form the second largest religious group in the U.K. and are one of the most rapidly growing minority groups, with 1.2 million more people identifying as Muslim between 2001 and 2011, representing a jump from 3 to 5 percent of the overall population (Office for National Statistics [ONS], 2013). Muslims in the U.K. form a heterogeneous and ethnically diverse group, with 68 percent from a South Asian background, 10 percent reporting as Black (African/Caribbean or British), and 11 percent identifying as ‘Other Ethnic Group’ (ONS, 2013). British Muslims are among the worst affected by health inequalities, and have the highest reported rates of illness and disability of all minority groups (Hussain, 2009; Sheikh, 2007). In the current political climate, where Muslims are increasingly portrayed negatively (Ahmed & Matthes, 2017), the mental health of this group is under particular threat (Sheridan, 2006; Ali, Milstein, & Marzuk, 2005; Ali, Liu, & Humedian, 2004). A study of Muslims living in Britain, France, and Germany found that perceived Islamophobia predicted higher levels of psychological distress and perceived stress (Kunst, Sam, & Ulleberg, 2013), and evidence suggests that South Asian populations in the U.K. have a heightened risk of psychological morbidity (Fazil & Cochrane, 2003). Minority ethnic groups face barriers to accessing mental health services, due in part to mistrust of mental healthcare professionals and stigma within communities (Bowl, 2007; Williams, Turpin, & Hardy, 2006; Keating & Robertson, 2004; NIMHE, 2004). A survey of 152 members of a Pakistani Muslim community by mental health charity Rethink Mental Illness (2007) found a consistent lack of uptake of mental health services. There is evidence that South Asian Muslims in particular are less likely to access mental health services than all other groups (Sheikh & Furnham, 2000). Services may also lack knowledge or understanding in approaching these groups, and are therefore commonly viewed as irrelevant (Weatherhead & Daiches, 2010; Bhui & Morgan, 2007; Ali et al., 2004). Muslims habitually turn to faith leaders at times of emotional and psychiatric difficulty (Dein, 2013; AlKrenawi, Graham, Dean, & Eltaiba, 2004; McCabe & Priebe, 2004; Cinnirella & Loewenthal, 1999). Barn and Sidhu (2005) interviewed 54 Muslim Bangladeshi women who identified imams and tradiMuslim Faith Leaders 25 tional healers as their main source of support in terms of seeking healthcare. Similarly, Dein, Alexander, and Napier (2008) report that a sample of Bangladeshi Muslims in East London turned to imams and traditional faith healers before seeing medical professionals. Another survey of 111 Muslims found that a majority believed in supernatural causes of physical and mental illness (including jinn possession and black magic), and 54 percent believed treatment should be sought from both doctors and religious figures simultaneously (Khalifa, Hardie, Latif, Jamil, & Walker, 2011). In an observational study of 123 patients attending an Early Intervention Service for Psychosis, Singh and colleagues (2015) found black and Asian patients were more likely to pursue help from faith organizations, although this did not result in their delayed presentation to mental health services. Imams: De Facto Mental Health Providers The traditional role of an imam is to lead prayer, conduct religious ceremonies, deliver sermons, and provide spiritual and religious guidance (Haddad & Lummis, 1987). The imam plays a central role in the communal and spiritual life of Muslims and has a great deal of trust and respect placed in them (Siddiqui, 2004). Since Sunni Islam does not have a formalized clergy system, most mosques do not operate with standardized religious hierarchy (Maqsood, 2008; Boender, 1999), and it can be difficult to clearly identify the providers of support in an Islamic context. There are a broad range of religious teachers, spiritual guides, and scholars based in mosques, community centers, and educational establishments, any of whom may be approached by members of the Muslim community struggling with psychological difficulties (Pilkingon, Msetfi, & Watson, 2011). All of these are encompassed here in the category ‘Muslim faith leaders’. Faith leaders may perform Ruqya, an Islamic prayer modality that uses recitation of Quran verses or supplications of the Prophet Muhammad for healing (York, PerezChisti, Lewis, & Yucel, 2011). Examining pastoral care provided within different faith groups, Leavey (2008) interviewed seven Muslim religious leaders who felt they were the first port of call for individuals in their community with psychiatric problems, more so than Christian and Jewish clergy. Across faiths, clergy are frequently frontline responders for congregants facing the onset of mental illness, and serve to facilitate these individuals’ access to a broader network of mental health services (Larson et al., 1988; Piedmont, 1968). This role is particularly significant in minority ethnic communities, given the context of high disparities in access to healthcare (Ali et al., 2005; Young, Griffith, & Williams, 2003). Despite the apparently central role played by Muslim faith leaders in the provision of support to individuals with psychological difficulties, highlighted 26 Sazan Meran and Oliver Mason by patients and religious leaders alike, there has been limited exploration of their role. What studies do exist in a U.K. context are qualitative in nature, utilizing a very small sample. For instance, Rashid, Copello, and Birchwood (2012) examined the views of eight Muslim faith leaders, including four imams, two shaykhs, one mullah, and one female religious teacher, on psychosis and substance misuse. The religious leadership simultaneously held medical and religious beliefs about the causes of mental illness, deploying both within the same narrative and finding no conflict between the two. Participants at times spoke about schizophrenia as having a biomedical etiology, requiring psychiatric intervention, and at other times stated they believed psychotic symptoms were caused by jinn possession. Similarly, Ally and Laher (2007) interviewed six Muslim faith healers in South Africa about the perceived causes of mental illness; this was sometimes held to have environmental or biological causes (stress, trauma, or chemical imbalances in the brain), although spiritual problems could present as mental illhealth. The healers claimed the ability to distinguish between spiritual illness with a supernatural cause, such as black magic or jinn, and mental illness. In another qualitative UKbased study, Watts, Murray, and Pilkington (2014) performed a phenomenological analysis of the experiences of six imams, all of whom saw providing counseling and pastoral care as a core part of their role and acted in a manner analogous to central diagnostic practitioners: Directing those with medical ailments to doctors, and those with jinn difficulties to a spiritual expert. Imams reflected that while they made referrals to medical services, a reciprocal relationship did not exist. A small number of quantitative studies have been conducted in the U.S. on the role played by imams in the mental health of Muslims. Ali and colleagues (2005) surveyed 62 imams across the U.S., and found that 95 percent spent a significant amount of time each week counseling congregants with psychiatric difficulties. However, imams were less likely than clergy from other faith groups to have formal counseling training. In a second study, Ali and Milstein (2012) utilized a vignettebased survey depicting an individual exhibiting symptoms of depression to assess imams’ beliefs about the etiology of mental illness and helpful interventions, as well as their referral practices and counseling experience. Their principal finding was that imams recognized the severity of serious mental illness and the necessity of some type of intervention in order to attain recovery. Imams were most willing to refer congregants to mental health professionals while continuing to provide counseling themselves. However, although imams recognized the validity of mental health interventions alongside religious interventions, actual referrals to mental health professionals were low. AbuRas, Gheith, and Cournos (2008) conducted a crosssectional survey of 22 imams and 102 Muslim worshippers in 22 mosques in New York City, and found that members of the Muslim community most frequently sought support for mental health issues from imams. The majority o

the journal of muslim mental health

Muslim Faith Leaders: De Facto Mental Health Providers and Key Allies in Dismantling Barriers Preventing British Muslims from Accessing Mental Health Care