Sarah Khullar
Although rates of mental illness are the same around the world, the number of people treated for mental health conditions differ greatly across countries (Kayrouz et al., 2018). In the Middle East, specifically, treatment rates of severe mental health disorders, such as non-affective psychosis, bipolar disorder, and depression, are significantly lower than the global prevalence of treatment for the same disorders (Kayrouz et al., 2018; WHO, 2017). Furthermore, stigma towards individuals with mental illness is more common in the Middle East in comparison to other regions, which might impact individuals’ choice of treatment (Sewilam et al., 2015). Of particular relevance are the beliefs and attitudes about mental illness that shape the perception of mental health services. Given the integral role of religion in everyday life, some individuals in the Middle East seek alternative options to cope with their mental health (Al-Krenawi, Graham, Dean, & Eltaiba, 2004; Ciftci, Jones, & Corrigan, 2013; Connors & Halligan, 2015; Corrigan & Penn, 1999; Zolezzi et al., 2018). Broader contextual factors, such as cultural values related to the family unit, also heavily impact one’s decision to seek out professional mental health services, especially considering the value placed on strong family units (Al-Krenawi et al., 2004; Gearing et al., 2012, 2015; Savaya, 1998). Thus, this review explores the following research question: how do the religious and familial values of Muslims in the Middle Eastern influence beliefs about mental illness and openness towards seeking mental health services?
Beliefs and Attitudes about Mental Illness from an Islamic Perspective
Islamic teachings on health stem from the Quran, the Holy Book, consisiting of revelations from God to the Prophet Muhammad, Hadiths (sayings of Prophet Muhammad), and Sira (Prophet Muhammad’s recorded actions and behaviors which are meant to serve as a guide for Muslims in certain situations; Bagasra & Mackinem, 2014; Haque, 2004). Those who adhere to the Islamic faith believe that God is all-knowing, and ascribe to the Quran’s assertion that faith provides security when faced with challenging life circumstances, as only God knows what is best for an individual (Haque, 2004). Muslims, thus, are taught to cope with mental health issues by seeking help from the Quran, asking God for help, praying, patience, faith, and hope (Haque, 2004).
Moreover, faith in Islam is seen as fostering positive mental health; having a strong relationship with God leads to a sense of empowerment. This premise leads some Muslims to believe that mental illness is a result of lack of faith (Mehraki & Gholami, 2017 Haque, 2014). In fact, Muslims in the Middle East often attribute spiritual reasons to causes of mental illness, believing that it is a punishment from God, or that one has been possessed by jinn, or evil spirits (Al-Krenawi et al., 2004; Ciftci et al., 2013; Sewilam et al., 2015). Others, however, attribute environmental and biological factors, such as chemical imbalances, stress, or genetics, as causes of mental illness (Al-Krenawi et al., 2009; Bagasra & Mackinem, 2014; Savaya, 1998).
Yet, many with this viewpoint also believe that the risk factors themselves serve as a test from God, or that they result from not following religious teachings on how to prevent mental illness through positive qualities (i.e., faith, patience and repentance; Bagasra & Mackinem, 2014; Mehraki & Gholami, 2017; Haque, 2004). When one breaks God’s rules, it can lead to feelings of psychological turmoil, or a sense of guilt (Haque, 2004). To alleviate these feelings, the Quran advises that Muslims engage in repentance as God loves to forgive, so long as one does not repeat the sin that they have asked forgiveness for (Haque, 2004). Consequently, some believe that strengthening one’s faith and repenting for one’s sins is a sufficient solution for problems that may arise in regards to mental health. Because patience is described in the Quran as a positive quality, which can cure all sorts of illness, there is a belief that one must be patient to see the results from these practices (Haque, 2004). Thus, some might avoid or delay professional help-seeking, given the importance that Islam stresses on patience and the promise of greater rewards as a result of suffering (Merhej, 2019). Overall, then, as a result of their religious values and beliefs, many Muslims will approach an Imam or a religious figure as one of the first steps in treating mental illness perhaps making individuals to be less open to seeking psychological or psychiatric treatment (Dardas & Simmons, 2015; Merhej, 2019; Savaya, 1998; Zolezzi et al., 2018).
Cultural Values and the Family Unit
Overall, Islam stresses the importance of taking care of one’s health by seeking professional treatment when needed, approaching illness with patience and prayer, and rejecting the stigmatization of others (Byrne et al., 2017; Haque, 2004). Thus, beliefs about mental illness stem largely from cultural values— and not from religious teachings (Dardas & Simmons, 2015; Kayrouz et al., 2018; Sewilam et al., 2015; Youssef & Deane, 2006; Zolezzi et al., 2018). Turning to religious leaders can often help mild symptoms of poor mental health through providing Sira and offering advice rooted in religion and religious values (Dardas & Simmons, 2015). However, turning to the family unit to alleviate mental health symptoms often precedes turning to religious leaders due to the important role that family plays in 12 | Literature Reviews Muslim communities (Ahsan & Ahsan, 2004; Savaya, 1998). Family and marriage provide emotional security and a stable environment to raise children, allowing parents to pass on Islamic teachings and the right morals and values to the next generation (Ahsan & Ahsan, 2004). From a cultural standpoint, an individual’s actions reflect upon the entire family unit; thus, the maintenance of family reputation and privacy heavily influences one’s behaviors (Abdel-Salam et al., 2019). Some may avoid seeking professional mental health services and might instead prefer to consult with those within the family and community religious leaders, often making individuals less open to seeking professional mental health treatment (AlDarmaki, 2003; Al-Krenawi et al., 2009; Gearing et al., 2012, 2015; Hassouneh & Kulwicki, 2009; Savaya, 1998).
Marriage also has cultural importance among Muslim families in the Middle Eastern region, often informing the social roles associated with women (Al-Krenawi et al., 2009; Ciftci et al., 2013; Gearing et al., 2015; Gearing et al., 2012). Culturally speaking, a man typically chooses a woman to marry (although women have every right to refuse or reject the offer); as a result, more focus might be placed on women’s reputations in an effort to avoid presenting as undesirable to prospective husbands (Dwairy, 2006). Additionally, due to the strong spiritual beliefs about the predictors of mental illness (e.g, being possessed by evil spirits called jinn), some people might believe the presence of a mental health disorder can prevent women from fulfilling their roles in the family unit, such as serving as the “child carer” of the family (Ahsan & Ahsan, 2004; Al-Krenawi et al., 2009; Ciftci et al., 2013; Gearing et al., 2012, 2015; Scull et al., 2014). In fact, those with mental health disorders can be seen as less intelligent, unable to look after themselves, and unable to handle responsibilities, all of which potentially limit marital prospects, as men might view these as negative qualities in a partner (Al-Krenawi et al., 2004; Bener & Ghuloum, 2010; Zolezzi et al., 2018). The potential negative impact on marriage prospects might consequently contribute to one’s willingness to seek professional mental health services, especially given that maintaining the family unit is a strong cultural value among Muslims living in the Middle East (Abdel-Salam et al., 2019; AlKrenawi et al., 2009, 2004; Kayrouz et al., 2018).
The shame associated with a severe psychiatric diagnosis or a family member’s behavior might also bring shame to the entire family, resulting in “associative stigma” (El-Islam 1994; Zolezzi et al., 2018). The Arabic word alwasm attributes shame by labelling individuals exhibiting socially and culturally unacceptable behaviors as unfit members of society (Dardas & Simmons, 2015). Furthermore, haram (religiously forbidden) is tied to religious doctrine and is used in circumstances when an individual acts in a manner alternative to religious requirements (Ajrouch, 2004). These terms label an individual’s behavior; however, they may also attribute blame to the family by implying that the individual’s family condoned or failed to teach an individual why that particular behavior is deemed haram or aib (Ahsan & Ahsan, 2004; Ajrouch, 2004). Beliefs that those Muslim communities (Ahsan & Ahsan, 2004; Savaya, 1998). with a mental illness should not get married, have children, and are unable to sustain friendships are often attributed to the shame and embarrassment others feel when associated with someone who has a mental illness (Zolezzi et al., 2018). Thus, an individual’s decision to seek treatment is often influenced by their attempt to avoid bringing associative stigma to their family, as family interests are often prioritized over individual interests (Abdel-Salam et al. 2019; Zolezzi et al., 2018).
Additionally, some women might experience even higher levels of shame due to a cultural belief that Muslim women represent a family’s sharaf, or honor (Abdel-Salam et al., 2019; Bener & Ghuloum, 2010). Consequently, some married women might be less likely to share mental health concerns with others or seek treatment, out of fear of harming their own reputation, as well as their family’s (Al-Krenawi et al., 2004). Given that many believe that the family unit serves as a source of emotional support and socialization, sharing personal issues outside the family might lead to negative attitudes towards the family (Ahsan & Ahsan, 2004). In fact, female Muslims express feeling hyper-aware of familial and societal expectations, particularly due to maintaining family honor and reputation – behaving in ways deemed socially appropriate – and acting in accordance with cultural gender roles (Abdel-Salam et al., 2019). Because maintaining family honor is an important cultural value in Muslim culture in the Middle East, the fear of shame can reduce a family member’s openness to seeking psychological or psychiatric care (Al-Krenawi et al., 2004). This, in turn, results in delaying seeking professional services until an individual displays severe symptoms, others have noticed the symptoms, or treatments through an Imam have been exhausted (Bener & Ghuloum; Dardas & Simmons, 2015).
Conclusion
Overall, Muslim religious and family cultural values influence the beliefs and attitudes associated with mental illness, informing how mental health is approached and addressed. In some communities, having a severe psychological disorder has implications for the family unit and marital prospects, perhaps reflecting a family’s inability to effectively teach Muslim religious and cultural values. Given the expectation of placing family interests before one’s own, individuals in the Middle East might not seek out professional mental health services. Yet existing literature rarely discusses the potential differences in openness to mental health services across generations, primarily due to the lack of research on specific age groups. Future studies might address this limitation, as there are generational differences in following Islamic values (Haque, 2004). Perceptions of mental illness also vary by level of education and exposure to Western or modern mental health services (Zolezzi et al., 2018). Culturally relevant models have crucial implications for the successful design and implementation of mental health interventions, as religion is a key contextual factor that influences the accessibility of treatment. Thus, psychological and psychiatric services Literature Reviews | 13 Openness Toward Mental Health Services should provide access to resources to increase knowledge on the causes, symptoms and treatment of mental illness, while also considering the potentially critical role of faith-based services in this population.
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