ATTITUDES TOWARDS HELP-SEEKING AMONG SOUTH ASIAN AMERICAN

MUSLIM WOMEN

by
Amina Mahmood

A thesis submitted in partial fulfillment of the

requirements for the Doctor of Philosophy
degree in Psychological and Quantitative
Foundations (Counseling Psychology)
' in the Graduate College of The University of Iowa

December 2008

Thesis Supervisor: Associate Professor William Ming Liu

 UMI Number: 3347233

Copyright 2008 by
Mahmood, Amina

All rights reserved.

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To my family (in the broadest sense of the word)

ii
It's good to leave each day behind,
like flowing water, free of sadness.
Yesterday is gone and its tale told.
Today new seeds are growing.

-Rumi, Whispers of the Beloved

iii
 ACKNOWLEDGMENTS

This project owes its completion to the faith, support, and guidance of many
individuals. First of all I would like to thank my family: Durray Shahwar I. Mahmood,
Sajjad Mahmood, Sajid Mahmood, Fatima Mahmood, and Bilal Mahmood. Thank you
for your unwavering confidence and support during my journey through graduate school.
Also to Eddie Etsey, thank you for your confidence and support, technical assistance, and
keeping me motivated to see this project to its completion.

To my research team, Leslie C. Leathers and Dr. Joy E. Moel. Thank you for
agreeing to work on yet another qualitative project together. Your genuine interest in the
research and the energy you provided are greatly appreciated. To Torrii Yamada, thank
you for serving as the external auditor and for going above and beyond by providing
extremely detailed feedback on this project.

To my advisor and dissertation chair, Dr. William M. Liu, thank you for your
mentorship, and guidance. I have learned, and continue to learn from your expertise.
To my committee members: Dr. Saba Rasheed Ali, Dr. Stewart Ehly, Dr. Meena R.
Khandelwal, and Dr. John Westefeld. Thank you for taking the time and energy to be on
my committee and providing valuable insight and feedback.

To Dorothy (Dottie) M Persson, thank you for your assistance with the initial
literature review for this project. Your knack for finding research literature amazes me!
Thank you to my friends and colleagues—especially those who were part of my graduate
school journey for believing that it would be possible one day to reach the finish line.
Lastly, I would like to thank the research participants. Thank you for sharing your stories,
without your open and honest conversations this dissertation would not have been
possible.

iv
 ABSTRACT

South Asian Americans are the fourth largest sub-group among Asian Americans,
and it thus becomes important to understand the definitions of psychological health and
wellbeing, and attitudes towards psychological help-seeking for this population.
Additionally, the American Muslim population is projected to become the second largest
religious group in the year 2010, and approximately one-third of the American Muslim
population is constituted of South Asians. Research on the South Asian population has
primarily been conducted in Great Britain and Canada, and has indicated that South
Asian women residing in the Western diaspora experience significant psychological
distress. This research has tended to ignore the intersection of religion and culture upon
the experience of psychological distress and coping methods. This study employed
consensual qualitative research to explore the definitions of psychological health and
wellbeing and attitudes towards help-seeking among South Asian American Muslim
women, a population that is more likely than their male counterparts to engage in help-
seeking behaviors. Thirteen South Asian American Muslim women between the ages of
20-35 participated in this study. Results of the study suggest that South Asian American
Muslim women maintain positive views of psychological help-seeking, and would prefer
to seek psychological services from a culturally sensitive provider. Participants utilized
multiple modalities to cope with psychological distress (including religion, and informal
support from friends, and family members). Another important finding of this study is the
need to increase psycho-educational efforts to this religiocultural community regarding
psychological services, as the lack of information, and misinformation about such
services acts as a preventative factor towards psychological help-seeking.

v
 TABLE OF CONTENTS

LIST OF TABLES viii

CHAPTER 1 INTRODUCTION 1
Overview 2
Help-Seeking and Asian Americans 3
South Asian Americans and Help-Seeking 4
American Muslims 6
Critique of the Research Literature 7
Definitions 8
Acculturation 8
Ethnic Minority 9
Help-Seeking 9
South Asian American Muslim Women 9
Conclusion 10

CHAPTER 2 LITERATURE REVIEW 11

South Asian American Muslim Women 11
Cultural Beliefs and Values 13
Perceptions of Psychological Health 17
Islam and American Muslims 24
Islam 24
Religious Beliefs and Values 26
Perceptions of Psychological Health 29
Psychological Health Concerns of South Asian Muslim Women 35
Summary 45
The Current Study 47
CHAPTER 3 METHODOLOGY 50
Consensual Qualitative Research 50
Theoretical Basis of CQR 51
Rationale for using CQR 53
Participants 54
Interviewees 54
Research Team 57
Researcher Biases and Expectations 57
Measures 58
Demographic Form 58
Interview Protocol 61
Procedures 61
Recruiting Participants 61
The Interview Process 62
Transcriptions 62
Data Analysis 63
Identification of Domains 63
Core Ideas 64

vi
 Cross-Analysis 64
The Auditing Process 65
Stability Check 66
Draft of Final Results 67

CHAPTER 4 RESULTS 68
Domains and Categories 68
Domain 1: Definitions of and attitudes towards psychological
health and treatment 68
Domain 2: Culture 72
Domain 3: Facilitators of seeking psychological help/treatment 76
Domain 4: Common Psychosociocultural Problems 80
Domain 5: Coping with psychosoiocultural concerns 84
Summary 86
CHAPTER 5 DISCUSSION 88
Domain 1: Definitions of and Attitudes towards Psychological Health
and Treatment 89
Domain 2: Culture 91
Domain 3: Facilitators of Seeking Psychological Help/Treatment 92
Domain 4: Common Psychosociocultural Concerns 94
Domain 5: Coping with Psychosociocultural Concerns 97
Limitations 98
Implications for Practice and Research 100
Practice Implications 100
Research Implications 101
Summary and Conclusion 102
APPENDIX A ADVERTISEMENT FOR STUDY 129

APPENDIX B PARTICIPANT SCREENING SCRIPT 131

APPENDIX C INFORMED CONSENT FORM 134

APPENDIX D INITIAL INTERVIEW PROTOCOL 141

APPENDIX E DEMOGRAPHIC FORM AND FINAL INTERVIEW

PROTOCOL 143
REFERENCES 153

vii
 LIST OF TABLES

Table

1. Participant Demographics 104

2. Summary of Participant Responses to Measures 106

3. Domains, Categories and Frequency of Participants' Responses 107

4. Participants' Endorsement of Categories Ill

viii
 1

CHAPTER 1

INTRODUCTION

By the year 2050 the majority of the U.S. population will be composed of ethnic

minority members, and White Americans will become the minority group (Miranda,

Nakamura, & Bernal, 2003). Due to the increasing diversity of the U.S. population,

psychologists will encounter an increasingly ethnically diverse clientele. Thus, it is

important for professionals to be aware of ethnic minority individuals' attitudes towards

help-seeking, that is, the actions and behaviors one engages in to obtain professional

psychological and mental health care services.

Although the psychological and multicultural literature has focused on many

aspects of diversity and diverse communities, one group still needing attention is South

Asian American Muslim women. Psychologists must understand the mental health needs

of South Asians because they are the fourth largest sub-group among Asian Americans

(Inman, Ladany, Constantine, & Morano, 2001), and American Muslims will be the

second largest religious group by 2010 (U.S. Department of State, 2001). Furthermore,

the needs of South Asian American Muslim women are especially important, considering

women are more likely than men to engage in help-seeking behaviors (Bradshaw, 1994).

Research on South Asian Americans has vastly ignored the differences between members

of the various religious groups, and the intersection between religion and culture (Inman,

2006).

Psychological literature on South Asian American Muslim women is lacking.

This is partially due to the scarcity of research on American Muslims in general and the

South Asian American Muslim sub-group in particular. Some research literature is

available on the South Asian American population, but attention has not been paid to the

religious sub-groups within this ethnic group.

Overview

The current study focused on the psychological health concerns and attitudes

towards help-seeking among South Asian American Muslim women. In this chapter an

overview of research examining attitudes towards help-seeking among Asian Americans

is provided. Next the need to understand the attitudes towards help-seeking among South

Asian American Muslim women, as well as some common psychological health concerns

of this specific population are presented. This is followed by definitions for some

commonly used terms in the literature review of the current study.

Chapter 2 synthesizes the research literature on help-seeking attitudes among

South Asian American Muslim women. A brief overview of South Asian and American

Muslim cultural beliefs and values, and views and perceptions of psychological health,

wellbeing and distress is provided. Clinical and research implications derived from the

literature review are summarized and the guiding research questions of the current study

are posed to gain further understanding of the attitudes towards help-seeking and

psychological health concerns of this population.

In Chapter 3 the qualitative methodology of the current study is further

explicated, and details of the procedures, that is participant recruitment, data collection

and analyses, composition of the primary research team, and description of the

participants is delineated.

The results of the study are presented in Chapter 4 in accordance with the

qualitative methodology used, and participant quotes are used to illustrate the results. In
the final chapter (Chapter 5) the results are discussed in detail with reference to the

hypotheses and literature reviewed. A discussion of the commonalities of current results

as well as new information gleaned from the current study is also presented. Finally, the

conclusion seeks to address future research directions to further expand the knowledge in

this area.

Help-Seeking and Asian Americans

Cultural and religious beliefs and values may shape one's worldview and

establish norms for health and behavior (Das, 1987). Research on Asian Americans'

attitudes toward help-seeking and willingness to seek counseling has yielded conflicting

results. Most of the research has been conducted on college students, and the participants

have been primarily Chinese, Japanese, Filipino and Korean ethnic groups (Atkinson &

Gim, 1989; Atkinson, Lowe, & Matthews, 1995; Gim, Atkinson, & Whiteley, 1990; Kim

& Omizo, 2003; Kim, Yang, Atkinson, Wolfe, & Hong, 2001; Solberg, Ritsma, Davis,

Tata, & Jolly, 1994; Tata & Leong, 1994; and Tracey, Leong, & Glidden, 1986). Other

ethnic groups are identified as South East Asian, or "other." The absence of Central

Asian participants (for example Afghanis, and Iranians), suggests that this ethnic group

may have been included in the 'other' category. Also, six of the eight studies reviewed on

Asian Americans' values and attitudes toward help-seeking collected data in California

and Hawaii (Atkinson & Gim, 1989; Atkinson, Lowe, & Matthews, 1995; Gim,

Atkinson, & Whiteley, 1990; Kim & Omizo, 2003; Kim, Yang, Atkinson, Wolfe, &

Honge, 2001; and Tracey, Leong, & Glidden, 1986). Only two of the studies explicitly

indicated the inclusion of South Asian American participants, and these were conducted

in the Midwest (Solberg et al., 1994; and Tata & Leong, 1994). Additionally, these
studies utilized survey research, and quantitative methodologies. Participants were

required to respond to acculturation (Suinn-Lew Asian self-identity acculturation scale,

Asian values scale), help-seeking (Attitudes towards seeking professional psychological

help scale, Willingness to seek counseling questionnaire), and psychological problems

identification inventories (Personal problems inventory).

These studies indicated that previous counseling experience is positively related

to help-seeking attitudes and behaviors (Atkinson, et al., 1995; and Solberg et al., 1994).

Asian American college students are more likely to access academic/vocational

counseling rather than seek help for emotional/social concerns. The quality of experience

during academic counseling may affect the likelihood of seeking help for personal

concerns for Asian American students (Atkinson, et al., 1995).

Kim and Omizo (2003) indicated that attention must be paid to within-group

ethnic differences when it comes to cultural values and attitudes toward help-seeking.

Kim et al. (2001) further emphasized this in a study that examined the similarities and

differences among Asian American ethnic groups and their cultural values. Specifically,

the use of services by Asian Americans may increase if current psychological service

providers begin collaborating with existing indigenous support systems in the Asian

American communities (Kim & Omizo, 2003), for instance, consulting with religious

leaders and traditional healers and participating in community events, thus increasing

outreach efforts to this community.

South Asian Americans and Help-Seeking

South Asian Americans constitute the fourth largest ethnic sub-group within the

Asian American population (Inman et al., 2001). The South Asian American population
 5

has been increasing rapidly since the passing of the 1965 immigration law in the United

States (Gupta, 1999). According to the 1990 census (as cited by Gupta, 1999), 35 percent

of Asian Indians (Indian and Pakistani) live in the North East, 24 percent live in the

South, 18 percent live in the Midwest, and 23 percent live in the West. California, New

York, New Jersey, Illinois, and Texas boast the highest concentrations of Asian Indians

(Indians and Pakistanis; Gupta, 1999). South Asians are likely to prefer residing in urban

areas (Gupta, 1999). According to the U.S Census Bureau's report (2002) approximately

1.9 million Americans consider themselves to be "Asian Indian" or part Asian Indian. In

addition to the 1.9 million Asian Indians there are approximately 153,533 Pakistani

Americans, 41,280 Bengali Americans, 20,145 Sri Lankan Americans, and 7858

Nepalese Americans composing the South Asian American population (U.S. Census

Bureau, 2002). Thus, the South Asian American population is composed of a little over 2

million individuals (2,122,816).

Research literature on South Asian Americans is lacking and not much is known

about their attitudes towards help-seeking, or resources accessed to cope with

psychological distress. Cultural and gender differences in help-seeking attitudes specific

to this sub-group may exist. South Asian Americans are diverse in terms of language and

religion, however similar cultural beliefs and values unite South Asian Americans.

Religion can and does influence the practice of South Asian culture and may be related to

attitudes towards help-seeking.

South Asians belong to many different religious groups. Within South Asian

American literature, however, little attention has been given to South Asian American

Muslims. India, the largest country in South Asia, has the second largest population of
 6

Muslims in the world. Bangladesh and Pakistan are primarily Muslim countries, whereas

Muslims are a minority group in Nepal and Sri Lanka. Literature on American Muslims

is scarce and tends to overlook ethnic differences among American Muslims.

American Muslims

American Muslims account for about 6-8 million of the United States population

(U.S. Department of State, 2001) today and are anticipated to be the second largest U.S.

religious group by the year 2010. Recent immigrants account for about a third of the

American Muslim population and belong primarily to South Asian cultures. South Asian

Americans constitute approximately one third of the American Muslim population

(Bagby, Perle, & Froehle, 2001; and Smith, 2005). South Asian American Muslim

women are more likely than men to seek help for psychological concerns (Khan, 2006).

Hence, it is of significance to review literature on the help-seeking attitudes of South

Asian American Muslim women and to identify research and practice implications as

indicated by the literature.

Psychological Health Concerns of South Asian American

Muslim Women: An overview

Research literature on psychological health concerns of South Asian women in

the Western diaspora is primarily obtained from studies conducted in Great Britain and

Canada. There are a few American studies examining psychological health concerns of

South Asian American women, which indicate that South Asian American women

experience psychological health concerns similar to their counterparts in Canada and

Great Britain.
 Extensive research in Great Britain has revealed that South Asian women have

higher prevalence rates for depression, suicide, self-harm, eating disorders, and body

image dissatisfaction than other ethnic groups (Anand & Cochrane, 2005). Pakistani

Muslim women in Britain are more likely to suffer from depression and anxiety than

other South Asian women, and White British women (Hussain & Cochrane, 2003).

Suicidal ideation is also more common among South Asian British Muslim women

(Anand & Cochrane, 2005). Domestic violence is another psychological health concern,

which has been identified by the research literature (Ahmad, Riaz, Barata, & Stewart,

2004; Ayyub; 2000; and Yoshioka, Gilbert, El-Bassel, & Baig-Amin, 2003). Negotiating

a bi-cultural identity, acculturation and immigration concerns, intergenerational conflict,

pre-marital dating and sexuality, and religious identity development are other concerns

that have been identified as concerning American Muslim women by Haque-Khan

(1997), and are likely to be of concern to South Asian American Muslim women.

Critique of the Research Literature

The research literature identified above and reviewed in Chapter 2 pertains

primarily to South Asian women in Great Britain, or Canada. It should be noted that the

context of immigration of South Asians to Great Britain is very different from that of the

United States. Although South Asians have been immigrating to the United States since

the 1800s the primary influx of South Asian immigrants to the United States occurred

following the passing of the 1965 immigration act (Gupta, 1999), and primarily

welcomed immigrants who were professionals. In contrast South Asian immigrants to

Great Britain primarily relocated to the country during a time when South Asia was a

British colony, and workers were needed in Great Britain to fill industrial positions.
 8

Hence, the South Asian immigrant population of Great Britain tends to encompass

greater social class diversity than does that of the United States. The context of racism

and discrimination in addition to the social class composition differs for South Asians in

Great Britain, with South Asians in Great Britain being targets of discrimination and

prejudice, and somewhat contentious race relations between South Asians and White

British citizens. South Asian Americans are viewed as a model minority (Das & Kemp,

1997), and thus the South Asian experience in the United States is qualitatively different

than that of its counterpart in Great Britain.

Due to the scarcity of psychological research literature on South Asian

Americans, the literature reviewed for the current study is derived from multiple

disciplines (including, psychology, social work, sociology, and anthropology), and

international (from Great Britain and Canada) literature. It should be acknowledged that

the difference in cultural, political, and historical contexts of immigration of South Asian

immigrants in Great Britain, Canada, and the United States, does limit the generalization

of the research literature to South Asian Americans.

Definitions

In this section definitions for some commonly used terms requiring clarification

are elaborated upon for the reader.

Acculturation

Level of acculturation to mainstream culture is related to help-seeking attitudes

and behaviors. Several studies have examined the relationship of acculturation to help-

seeking among Asian Americans. Acculturation has been conceptualized in various ways.

For the purposes of the current study acculturation is defined as a minority group's level
 9

of acceptance and adherence to the values of the dominant cultural group. For example, a

South Asian American woman who is highly acculturated to mainstream American

culture (that is, European American culture) adheres to an individualistic worldview

compared to an Asian American, who is less acculturated.

Ethnic Minority

The term ethnic minority rather than racial minority is used to place the focus on

how ethnic culture informs attitudes and help-seeking behaviors rather than examining

the impact of racial identity (that is, the socially constructed definition of race which is

based on phenotypical characteristics).

Help-Seeking

For the purposes of this dissertation study help-seeking refers to the actions and

behaviors engaged in to obtain professional psychological and mental health care

services, for example, seeking out a social worker, meeting with a psychologist for

psychotherapy. This is certainly a culture-bound definition, and one purpose of the

current study was to learn how this definition varied for the population of interest. Note,

that the terms psychological health and illness, and mental health and illness are used

interchangeably in this text.

South Asian American Muslim Women

The term South Asian and South Asian American refers to individuals of

Pakistani, Indian, Bengali, Sri Lankan and Nepalese heritage only. South Asians who

have been living in African countries for several generations, and those who are citizens

of Fiji, Guyana, and the West Indies have been excluded due to cultural idiosyncrasies
particular to the regional cultures. The reader should note, that the terms South Asian

women, South Asian American women, and South Asian American Muslim women, are

used interchangeably in Chapter 2. These terms are used synonymously due to the

scarcity of available research literature on the population of interest (that is, South Asian

American Muslim women). An assumption is made that available research literature on

South Asian women, and South Asian Muslim women residing in the Western diaspora

(that is, North America, and United Kingdom) is applicable to the population of interest.

Conclusion

A brief overview of attitudes towards help-seeking among Asian Americans and

South Asian Americans has been provided. An outline of psychological health concerns

of South Asian Muslim women in the Western diaspora indicates that this population

experiences significant psychological distress. There is limited information on attitudes

towards help-seeking among South Asian American Muslim women, a population that is

rapidly increasing in the United States. Next, a detailed examination of the religious and

cultural beliefs and values of South Asian American Muslim women is provided. The

impact of this religiocultural identity upon the perceptions and definitions of

psychological health, wellbeing and distress, and attitudes towards help-seeking is

explored, and the methodology and results of the current study which examined the

definitions of psychological health and wellbeing and attitudes towards help-seeking is

presented.
 11

CHAPTER 2

LITERATURE REVIEW

This chapter synthesizes the research literature on help-seeking attitudes among

South Asian American Muslim women. First a brief overview of South Asian cultural

beliefs and values is provided. This is followed by an introduction to the religious beliefs

and values of the American Muslim population. Next, literature, empirical and conceptual

pertaining to South Asian and American Muslims' views on mental health and wellbeing,

seeking psychological services and attitudes towards seeking psychological help is

reviewed. This is followed by a review of previous empirical research on attitudes

towards seeking psychological or mental health services and perceptions of help-seeking

pertaining to the population of interest. Finally, a summary providing clinical and

research implications is presented, and the current study that sought to explore the

attitudes towards help-seeking and psychological concerns experienced by this

population is introduced.

South Asian American Muslim Women

To conduct a thorough literature search several databases and search engines were

utilized, including: Psyclnfo, ERIC, PubMed, Ebsco Academic Search Elite, Sociological

Abstracts, PAIS International, Education full text, Global Health, and Web of Science.

Literature searches were conducted by using several generalized and some specific key

words so that a wide breadth of literature could be accessed. Key words used to conduct

searches included: "attitudes towards therapy", "help-seeking", "help seeking behavior",

"health care utilization", "health care seeking behavior", "ethnic minorities", "mental

health services", "Asian Studies", "South Asians", "South Asian cultural groups" "Asian
 12

Americans", "mental health", "South Asians" and "attitudes", "South Asians" and

"mental health," "Islam", "Muslims."

Global Health, PAIS International and the Sociological Abstracts databases

yielded the most results. Much of the literature pertaining to South Asian American

women was referenced in the Sociological Abstracts databases. Global Health and PAIS

International were helpful in locating literature pertaining to South Asian Muslim

women. All of the databases accessed cited references for general articles on Islam and

Muslims, ethnic minorities and help-seeking, with some specific references for South

Asians and South Asian Muslims in general, and South Asian women in particular.

The South Asian American population has been rapidly increasing post-1965. It

should be noted that South Asians have been immigrating to North America (United

States and Canada) since the 1800s. These earlier immigrants came primarily because of

economic reasons and are known as sojourners as their focus was to earn money for their

families and return to their homeland (Gupta, 1999). South Asian immigrants to the

United States and Canada in the early 1900s were primarily male, and were working to

support their families in South Asia. These men were able to bring their families to the

United States in 1945 under the family reunification program (Gupta, 1999). Thus, the

majority of South Asian women who immigrated to the United States did so as spouses,

and dependents of the South Asian men (Gupta, 1999). Although more South Asian

women have immigrated independently to the United States since the passing of the 1965

immigration act, the majority of current South Asian immigrants are still male (Gupta,

1999).
 13

Cultural Beliefs and Values

Behaviors and expectations are shaped by cultural beliefs and values, which are

influenced by one's ethnic, linguistic, religious, and historical background as well as

one's gender (Ahmed & Lemkau, 2000). South Asian American cultural beliefs and

values overlap significantly with those of other Asian American ethnic and cultural

groups. Literature on Asian Americans has established certain common cultural factors.

Leong (1986) identified several of these cultural factors in his review of the literature of

counseling and psychotherapy with Asian Americans. The identified factors include: the

historical experience of Asian Americans in the United States, including current racism

and discrimination; the somatization of psychological symptoms; a lower tolerance for

ambiguity indicating a preference for problem-solving psychotherapy rather than process-

oriented or insight-oriented psychotherapy; deference to authority; restricted emotional

expressivity through verbal and non-verbal communication; and the likelihood of

inaccurate assessments due to the assessment instruments being normed in predominantly

European American samples (Leong, 1986).

Some cultural beliefs and values of South Asians are listed by Ahmed and

Lemkau (2000) and are also mentioned in other research literature (Dasgupta, 2002;

Inman, 2006; and Naidoo, 2003). South Asian culture, like other Asian American

cultures is collectivistic (Sue & Sue, 2003). The family rather than the individual forms

the basic unit of the South Asian society. All actions undertaken by an individual are a

reflection on the family. Thus, a South Asian college student who graduates with honors

will be a source of pride to the family, whereas a college student who is failing classes

due to test anxiety will bring shame to the family and thus (s)he will deal not only with
 14

her/his own anxiety but also with the anxiety and the guilt of the reflection his/her

performance in college has on the family. The dynamics of guilt and shame play a major

role in South Asian culture (Ahmed & Lemkau, 2000; Dasgupta, 2002; and Inman,

2006). South Asians may restrain their true emotions in favor of maintaining the harmony

in the family unit (Ahmed & Lemkau, 2000).

The literature also describes South Asian culture as being patriarchal, and

structured with rigid gender roles (Ahmed & Lemkau, 2000; Das & Kemp, 1997; and

Dasgupta, 2002), however, this is a generalization as South Asian women exert

significant authority in, and contribute extensively to the family unit, as well as society at

large. The family unit is not limited to the nuclear family, rather extended family

members, that is, uncles, aunts, cousins, and grandparents, are included in the South

Asian definition of immediate family. South Asians rely extensively on their families for

emotional support, and financial support, if needed. It is expected that the family will

support the individual at all times.

In traditional South Asian homes, men are the breadwinners and heads of the

household. Women are mothers, homemakers, and nurturers of the family. Women's

identities are contingent upon their relation to the men in their lives, e.g. a wife, mother,

daughter, sister (Jayakar, 1994). It should be noted that social class status and educational

level determines the definition of gender roles. For instance, many middle and upper

class South Asian women are working professionals, and women from the lower social

classes also work outside the home to provide for their families. South Asian women like

other ethnic minority women (Bradshaw, 1994) also bear the responsibility of being the
 15

culture bearers and transmitting cultural and religious traditions to the younger generation

(Dasgupta, 2002).

Heterosexual marriage is encouraged in South Asian culture; homosexuality is

traditionally not recognized or accepted. Arranged marriages still occur within the South

Asian American community. It is very common and expected to involve one's family in

the decision making process for one's prospective life partner. Dating is not part of South

Asian culture, and hence the issues of dating, premarital sex, and the cultural lifestyle of

the American adolescent cause intergenerational conflict among South Asian American

immigrants and their American born children (Ahmed & Lemkau, 2000; Dasgupta, 2002;

and Inman, 2006). It is unclear whether similar intergenerational conflict regarding

relationship issues exists between second and third generation South Asian Americans, or

if this is limited to recent immigrants and their first generation American offspring. South

Asian culture also places an emphasis on marrying within one's ethnic group and within

one's social class standing (Das & Kemp, 1997). Therefore, another issue of contention

among South Asian Americans is interracial and interfaith marriage, as well as marriages

outside of one's social class (family opposition is likely to be voiced if the prospective

partner belongs to a lower social class standing).

South Asian American women's sexuality and social lives are monitored more

than the lives of South Asian American men. This is due to the value placed on the

chastity and virginity of the South Asian woman, and also the expectation that a South

Asian woman be a bearer of culture.

South Asian culture places great respect on elders and individuals in positions of

authority (Sue & Sue, 2003). Respected members of the family and elders in the
 16

community are sought for important decision-making purposes, and for advice. It is quite

common for South Asian adults to seek the advice of their parents when making minor or

major decisions, for example, consulting with the parent on what type of microwave to

buy or which job proposal to accept. This behavior can be misinterpreted, as dependence

through Western lens, but is an indicator of healthy familial relationships in South Asian

culture. The communication style of South Asians is to avoid direct eye contact and, like

other Asian American groups, restrain emotionality (Sue & Sue, 2003).

Religion tends to play an important role in the lives of South Asians, informing

the cultural beliefs and values that South Asians hold and serving as a coping mechanism.

For instance, South Asian Muslims turn to prayer as a means of coping when in distress

(Ahmed, & Lemkau, 2000). They place great importance on transmitting and following

the religious practices (Sodowsky, 1995 as cited in Das & Kemp, 1997). In addition to

closely following their religion, many South Asians tend to be superstitious (Ahmed &

Lemkau, 2000). For instance, it is common to see South Asian babies with either a black

thread tied around their arms as bracelets, or around their necks as necklaces, or black

dots on their foreheads, to signify protection from the "evil eye."

South Asians tend to seek help for physical and psychological concerns from

traditional healers, and turn to traditional herbal and behavioral remedies before seeking

professional medical or psychological help (Hilton, Grewal, Popatia, Bottorf, Johnson,

Clarke, et al., 2001). Another cultural behavior is the designation of hands for specific

tasks. For example, the right hand is used for eating and other sanitary activities, whereas

the left hand is used for non-sanitary activities such as cleaning oneself after using the

bathroom (Ahmed & Lemkau, 2000).

 17

Despite overall cultural similarities, South Asians do not all speak the same

language or practice the same religion. South Asians belong to different linguistic groups

depending on the geographical location of their ancestry. Many South Asians are

bilingual if not trilingual. Many speak their local dialect, the national language of their

country of origin, and English, the language of the colonizer. South Asians belong to

different religious groups including: Islam, Hinduism, Sikhism, Christianity, and

Buddhism.

Perceptions of Psychological Health

South Asians believe psychological health and wellbeing are directly linked to

physical health. South Asians take a holistic view of health; the psychological and the

physical are therefore interconnected so that a balanced life leads to physical wellbeing

(Hilton et al., 2001). Ayurvedic medicine, an ancient Indian holistic healing system,

combined with various traditional approaches to healing, including herbal remedies and

seeking spiritual healing from pirs (native healers), is commonly accessed for help with

psychological concerns as well as medical concerns. Ayurvedic practice takes a mind-

body approach to healing, and focuses on establishing balance within the individual.

Therefore, ayurvedic treatments are tailored to each individual (National Institute of

Ayurvedic Medicine, 2006). A research study conducted in Canada confirmed that

Canadian South Asians prefer traditional approaches to healing, including herbal

remedies, and advice from pirs prior to utilizing traditional Western medical or

psychological health care services (Hilton et al., 2001).

There is a strong cultural stigma against psychological illness in the South Asian

community. This cultural stigma refers to the negative attitudes held by the individual
 18

and her/his larger community regarding psychological health concerns. For instance,

psychological illness is viewed as a sign of weakness in the individual, and

acknowledging problems with one's psychological health will shame the individual and

her/his family, and potentially ostracize her/him from the community. Racial and cultural

stereotypes exacerbate cultural stigma in ethnic minority communities. Gary (2005)

introduced the concept of "double stigma" that is faced by ethnic minorities, which acts

as a barrier to seeking psychological services. Double stigma refers to the stigma of

belonging to an oppressed group (that is, an ethnic minority group), with the additional

stigma of mental illness. This double stigma combined with a general distrust of mental

health care may be related to ethnic minority group members choosing to cope privately

rather than seeking help (Cinnirella & Loewenthal, 1999; and Gary 2005). Similar to

other ethnic minorities, Asian Americans underutilize psychological and other mental

health services, express distrust towards the health care system, and prefer to access

traditional healing methods in their communities to address psychosocial stressors (Kim

& Omizo, 2003; and Sue & Sue, 2003).

In South Asian culture mental illness is believed to run in families (Ahmed &

Lemkau, 2000; and Jayakar, 1994) and therefore families with members who experience

chronic mental illness try to keep this knowledge hidden from others. This cultural stigma

against mental illness has significant implications for the individual and their families.

For instance an individual who has family members with mental illness or that have

suffered from psychological problems will likely be placed under great scrutiny when

searching for a spouse, even if the individual is psychologically healthy. South Asian
 19

families will hide minor psychological concerns as well as a history of more severe

psychological concerns in order to protect the family image.

Religion partially determines how individuals conceptualize their problems,

which coping mechanism they use, and where help is sought (Anand & Cochrane, 2005).

South Asians are likely to access help from various sources simultaneously, including

prayer, meditation, seeking help of a respected religious or spiritual leader including pirs,

consulting family members and elders, taking herbal medicine, and seeking medical or

psychological help (Anand & Cochrane, 2005; Das, 1987; and Hilton et al., 2001).

Das and Kemp (1997) postulated three factors that may inhibit South Asians from

seeking psychological help. They stated that the cultural value of keeping personal

problems to oneself and only disclosing problems to trusted family members and/or

elders is in contradiction to traditional psychotherapy which requires one to disclose the

most intimate details to a stranger. Secondly, South Asians want to live up to the "model

minority" myth, and acknowledging a psychological problem discredits the perception of

the South Asian community as a "model minority." Finally, South Asian cultural values

are inherently in conflict with counseling and psychotherapy, and even second generation

South Asians who have been raised in America and are more acculturated than their

immigrant parents will be hesitant to seek psychological services as doing so is in

opposition to their value of being loyal to the family. Das and Kemp (1997) and

Bradshaw (1994) also stated that South Asian Americans are more likely to seek

professional psychological care after all other interventions have been exhausted.

Literature on help-seeking among Asian Americans reveals that Asian American

women are more likely than Asian American men to access psychological services and to
 20

view psychological services somewhat positively (Solberg et al., 1994; and Tata &

Leong, 1994). South Asian American women are more likely to experience psychological

illness than are South Asian American men. This trend mirrors that of the majority group

(that is, White women are more likely to experience psychological illness than are White

men; Bradshaw, 1994) and of other ethnic minority groups. This may be due to the

difference in socialization of women in Asian American cultures where a greater stigma

is attached to a male who seeks help than is attached to a female seeking help (Sue &

Sue, 2003). Gender has not been explored as playing a primary role in help-seeking

attitudes and behavior. Religion, which is an important component of one's identity, and

often shapes one's ethnic identity and influences one's culture, has also been overlooked

in the research literature.

Bradshaw (1994) explained that greater prevalence of psychological illnesses

among women could be accounted for by the fact that women are victims of multiple

oppressions more often than men. Therefore, it is not surprising that South Asian

American women experience greater psychological distress than men, as not only do

these women carry the burden of being the culture bearers and transmitters, they also live

in dual worlds: South Asian culture, in which traditionally they might be expected to be

passive and obedient South Asian women; and mainstream American culture in which

they are strong independent women (Dasgupta, 2002; and Handa, 2003).

Additionally South Asian American women who have been born and raised in the

U.S. and are acculturated to mainstream U.S. culture (i.e. European American) possess a

greater awareness of and are exposed to the racialized nature of American society, and

hence are greatly affected by the racism and discrimination they experience in their daily
 21

lives, particularly in response to the visible aspects of their ethnicity and culture (Inman,

2006).

Atkinson and Gim (1989) reported that Asian Americans who are more

acculturated are more likely to seek psychological help. Similarly, Kim and Omizo

(2003) found that greater adherence to Asian cultural values (i.e., enculturation) is

associated with lower likelihood of seeking help. On the contrary, Tata and Leong

(1994), and Gim et al. (1990) reported that Asian Americans who are less acculturated to

the mainstream individualistic culture are more willing to seek help. Tata and Leong

(1994) postulated that Asian Americans who endorse individualistic cultural values view

themselves as self-reliant and thus would be hesitant to seek help. However Asian

Americans who are less acculturated and adhere more to traditional Asian values are

more likely to seek help through their social support network (that is, family, friends,

trusted community members) and are thus amenable to seeking out professional

psychological help (Gim et al., 1990; and Tata & Leong, 1994). As previously mentioned

in Chapter 1 these studies were primarily quantitative (that is, utilized acculturation and

help-seeking inventories rather than semi-structured or open-ended interview questions)

and the samples were composed of Asian American college students (predominantly

Chinese and Japanese Americans). Due to similarities amongst Asian American cultures

some of these results are likely to generalize to the South Asian American population.

Level of acculturation to mainstream American culture in addition to impacting help-

seeking behaviors may also influence the types of problems faced by South Asian

American women.
 22

The National Asian Women's Health Organization [NAWHO] (1996) conducted

a health needs assessment of South Asian American women residing in three California

counties from July 1994 through January 1995 (Alameda, Santa Clara, and Sutter) called

the South Asian Women's Health project (SAWHP). The purpose of this project was to

create an awareness of the health issues and concerns experienced by South Asian

American women in the area, and to contribute to the scarce literature on the health needs

of this population (NAWHO, 1996). Qualitative and quantitative data collection methods

were employed. Quantitative data was primarily collected through government agencies

(such as, California State Health Services Department, State and County Social Services

Department, United States Census) and included information on the demographics of this

population. Qualitative data was gathered by conducting in-depth interviews with eighty-

five participants, either face-to-face or on the phone, and via special interest focus groups

(consisting of: mental health providers, second generation young women, older second

generation women, lesbian and bisexual women). Interviews explored South Asian

American women's perceptions of health needs and concerns, the role of culture upon

these needs, and access to health care services. Focus group participants were asked to fill

out questionnaires, however the composition of the questionnaire was not detailed in the

study. The sample of South Asian women was representative of the social class diversity

within the South Asian American community (for instance, business professionals,

homemakers, students, health care providers, industrial workers, and white collar

workers).

Findings from this project identified several health concerns of South Asian

American women. Results indicated that the collectivistic nature of South Asian culture
 23

made South Asian women less likely to seek help for their mental health concerns.

Additionally, it appeared that South Asian women similar to women of other ethnic

groups are socialized to be caregivers and are more likely to overlook their own needs.

Participants were less likely to seek out a South Asian therapist for treatment due to fear

that others in the community would find out about their personal concerns (NAWHO,

1996). Others were hesitant to seek psychological treatment based on previous experience

in which culturally inappropriate treatment was provided by the mental health care

professional. South Asian psychologists interviewed for this project indicated that South

Asian women are more likely to seek and remain in psychotherapy if they are provided

with a detailed description of psychotherapy and the gains that they can expect to make

from seeking services (NAWHO, 1996). This description helps to erase ambiguity about

psychological services and to increase the comfort level in accessing and utilizing

psychological services.

Health concerns identified by this project included mental health (terms used to

describe concerns included: guilt, stress, isolation, and pressure), nutrition (difficulty

finding ingredients and foods which are part of the traditional South Asian diet) and body

image concerns (eating disorders were a big issue for the South Asian American women

participants), occupational health concerns (working long hours, work-related stress),

violence (domestic violence, child abuse, and elder abuse), and reproductive and sexual

health (NAWHO, 1996). Although this assessment was conducted in Northern California,

results from it are likely to generalize to South Asian American women in other

geographical regions of the country.

 24

Results from this study indicated that South Asian American women do

experience psychological stressors and illnesses. Identification with collectivistic cultural

values and lack of information about psychological services, however, serve as barriers to

help-seeking. Further research with South Asian American women in other regions of the

United States would be helpful in understanding the similarities and differences between

South Asian American women, especially pertaining to the psychological concerns that

they face. It is also important to learn the meanings South Asian American women assign

to psychological services and psychologists. Additionally, the role of religion in the lives

of South Asian American women needs to be addressed as it may influence help-seeking

behaviors and types of resources sought.

Islam and American Muslims

Islam

Islam is a religion followed by over 1.2 billion people around the globe and is the

second largest religion in the world (Esposito, 1998). Followers of Islam are called

Muslims. Islam was revealed to the Prophet Muhammad (peace and blessings be upon

him [this is the usual statement which follows any reference made to the Prophet

Muhammad, from this point on it will be implied rather than stated in the text]) via the

archangel Gabriel in 7* century Arabia. Muslims believe that the archangel Gabriel

revealed the word of Allah (Arabic term for God which is generally used by Muslims, as

well as Arab Christians) to the Prophet Muhammad. These revelations brought to the

Prophet Muhammad via Gabriel are organized into the Qur'an, which is the holy book of

Islam and provides universal guidance for Muslims. Muslims believe that Islam is a
 25

continuation and completion of Judaism and Christianity, and thus followers of the

Judeo-Christian traditions are highly regarded within Islam.

There are five foundational principles or 'pillars' of Islam which are followed by

all Muslims regardless of cultural or ideological differences. These five foundational

pillars form the basis of Islamic religious practices and are composed of:

1. Tawhid: the belief that there is only one God and that Prophet Muhammad is

the final prophet;

2. Salat: daily prayers, which Muslims are required to say five times a day, five to

ten minutes per time, evenly distributed throughout the day: before sunrise, mid-day, late

afternoon, sunset, and at night after the sun has completely set and before going to bed;

3. Zakat: giving charity, requiring Muslims to give a minimum of approximately

2.5% of their wealth to those in need annually;

4. Sawm: fasting during the month of Ramadan in the Islamic calendar, which is

based on the lunar year, creating rotation of the month through all four seasons, when

healthy adult Muslims refrain from eating and drinking during the daylight hours; and

5. Hajj: pilgrimage to Makkah at least one time if one's health and finances allow.

Other traditions followed by Muslims include specific dietary practices (no consumption

of pork or alcohol), modesty in dress and attitudes (hijab), and a high emphasis on

heterosexual marriage (Ali, Liu, & Humeidan, 2004).

American Muslims are a diverse group (Afridi, 2001; and Haddad, 2000).

Although all Muslims agree on the basic beliefs and tenets of Islam, significant religious

and ideological differences do exist. The primary split among Muslims is between the

Sunnis and the Shia (Mahmood, 2006). The Sunnis comprise the majority of the world's
Muslim population whereas the Shia comprise approximately 15-18 percent of the

population (Mahmood, 2006). Historically Shiites have been oppressed by the Sunnis

who, due to being the majority, have usually formed the governments and held positions

of authority in majority Muslim nations. This has resulted in Shiism placing a greater

emphasis on social justice and acting against oppression than Sunni Muslims. There are

further divisions within Shiism but the majority follow "Twelver Shiism" (Mahmood,

2006) and as mentioned previously regardless of which faction or sect a Muslim follows

the commonalities among Muslims regarding religious beliefs and practices far outweigh

the differences.

Religious Beliefs and Values

Islam places great emphasis on the family. The family forms the basic unit of

society in Islam, and the focus of the individual is to work towards the well being of the

family. Many religious traditions and cultural fables reiterate the importance of

strengthening the family unit. Similar to South Asian culture the Muslim's definition of

family includes extended relatives. Great importance is given to consulting with the

elders including trusted family and community members when it comes to making

important decisions. Overall the importance given to the family by Muslims suggests that

regardless of ethnic background Muslims tend to be more collectivistic in their cultural

orientation. To maintain the unity and to strengthen the family unit great importance is

placed on heterosexual marriage. Muslims are strongly encouraged to marry within their

faith, and many immigrant Muslims give preference to marrying within their ethnic

group. The proscription on premarital physical relationships in Islam, in addition to the

disdain towards Western-style dating has resulted in an issue of contention and cause for

intergenerational conflict among American Muslims (Mahmood, 2005).

Gender roles in Islam are not as stringent as some culturally based gender roles,

for instance those mentioned in the section on South Asian cultural beliefs and values.

Men and women are considered equal in Islam and are encouraged to work together for

the benefit of the family, and community at large. The differences between the two

genders are acknowledged but these differences are viewed as strengths that complement

those of the opposite gender (Ali, 2006). Parenthood is greatly valued and it is expected

that Muslim men and women will choose to be parents. Motherhood is highly respected

and many women choose to be stay-at-home moms. According to the teachings of Islam

women can choose whether they would like to be employed outside the home or if they

prefer to be stay-at-home moms. There are cultural restrictions that are placed on the

roles that women play in society that are oftentimes more severe than religious

guidelines.

Guidelines for interactions between men and women vary depending on ethnic

and cultural backgrounds, as well as on the individual's level of religious conservatism or

lack thereof. Cross-gender interactions of American Muslim girls and women are

monitored closely, and are limited more than that of American Muslim men. As in South

Asian culture unmarried Muslim women are expected to be chaste and virgins. In Islam

this is also an expectation for Muslim men, however due to cultural influences the actions

and behaviors of women are guarded more than those of men.

For many American Muslims, cross-gender interaction includes dressing and

behaving modestly, by avoiding provocative, seductive clothing and flirtatious behavior

 28

(Mahmood, 2005). Although the Qur'an prescribes modesty in dress and behavior for

men and women these guidelines have been interpreted differently, and the focus has

typically been on Muslim women not Muslim men. Some American Muslim women

choose to assert their religious identity by wearing the traditional headscarf, also called

the hijab. Hijab broadly means modesty and is prescribed for both men and women and it

should be evident in the behavior and dress of both sexes. In popular terminology hijab

connotes the visible head covering that some Muslim women choose to practice and it

has become a visual symbol of Muslim identity and at times of the oppression of Muslim

women. Although many American Muslim women choose to wear the hijab or head

covering some women may be required to wear the hijab and dress conservatively

because of cultural and familial expectations. Therefore, it cannot be assumed that a

Muslim woman observing the hijab identifies strongly with Islam, or if she is merely

fulfilling a cultural requirement (Mahmood, 2005).

Cultural practices are usually not synchronized with Islamic teachings when it

comes to providing equal opportunity to both males and females. American Muslims

place great importance on educating their children. However many American Muslims,

mostly recent immigrants place great importance on careers which require a professional

or advanced educational degree such as medicine, law, and engineering. First and second

generation American Muslims are often pressured to choose from these "acceptable"

careers and sometimes have to forgo a career or educational degree of their liking in

order to appease their parents. It is usually extremely difficult for young American

Muslims to consider joining the workforce directly after completing high school due to

familial pressures to pursue a college education.

 29

The Muslims in American Public Square (MAPS) project (Project MAPS, 2004)

indicated that 58% of American Muslims hold at least a college degree, thus illustrating

the importance given to education. The discrepancy between parents and their children

about acceptable career paths is another source of intergenerational conflict and stress.

Psychologists at university counseling centers are likely to see American Muslim college

students who are conflicted about which subject to major in. It would be important for the

psychologist to acknowledge the collectivistic values that the American Muslim college

student harbors and to consider the implications the decision made will have on the

family, and in turn the psychological impact of the response on the student (Mahmood,

2005).

A brief overview of some general religious values that interact with culture to

influence the worldview of American Muslims was provided in this section. Inevitably

these values will assist psychologists and other health care providers in gaining a

cohesive understanding of American Muslims and will enable health care providers to

better determine an appropriate treatment modality for their American Muslim clients.

Following is a brief explanation of the general definition of psychological health from an

Islamic perspective, and perceptions of psychological health and wellbeing.

Perceptions of Psychological Health

Muslims like South Asians generally take a holistic perspective towards

psychological health; personality is composed of body, mind, and spirit (Ansari, 2000).

For Muslims, Islam is a complete way of life; there is no distinction between the religious

and the secular. Thus, every problem may be resolved by viewing it through a religious

perspective. Imam Ghazzali (1058-1111 A.D.), and Abu Ali Al-Husain Ibn Sina (980-
 30

1037 A.D) better known as Avicenna in the western world), two famous Muslim scholars

and philosophers spoke about psychological distress in their works. Ghazzali spoke of

psychological distress in terms of spiritual distress. He stated that the body, mind and

soul are interconnected and all three components experience distress that can be

alleviated by spiritual healing (Haque-Khan, 1997). Ghazzali defines emotional suffering

as "separation between nature and reality" (Haque-Khan, 1997). Ibn Sina practiced

holistic medicine and wrote a comprehensive medical treatise in which he explained that

the body is composed of the soul, spirit and emotion and that in order to heal the

individual all of these components need to be treated (Carter & Rashidi, 2004).

Amini (1997) identified the "heart" as central to psychological wellbeing; a

sickness of the heart symbolizes distress or possible mental illness. It is important to note

that many Muslims tend to somatize psychological illness, and it is common for Muslims

to describe psychological distress affecting the heart. Many Muslim scholars in the early

history of Islam (8th through 12th centuries) contemplated psychological health and illness

and took a holistic stance to psychology and psychotherapy, emphasizing the mind-body

connection, and linking psychology to medicine (Haque, 2004).

Muslims believe that psychological health is established by following the

guidelines of Islam as mentioned in the Qur'an and the teachings of the Prophet,

remembering Allah, and engaging in morally correct activities (Ali, 2006; Amini, 1997;

and Mahmood, 2006). The Qur'an, and teachings of the Prophet Muhammad provide

Muslims with the guidelines for a psychologically healthy life. This perception of

psychological health and wellbeing implies that the need for psychotherapy occurs when

one is straying from the religion (Ali, 2006), and hence there is a great deal of shame
 31

attached to seeking help. The perception that straying from the religion causes distress

hinders Muslims from seeking psychotherapy. Muslims are taught mistakes can be

forgiven and ought to be forgotten. Thus if the distress a Muslim is experiencing is due to

one's actions and behaviors forgiveness from God can be sought and is granted

incumbent on the sincerity of one's intention. Once a Muslim has repented it is as if (s)he

is making a fresh start and (s)he is encouraged not to mention past mishaps, rather

emphasis is placed on focusing on the present and the future.

Muslims tend to engage in religious coping, for example, turning to prayer,

recitation of the Qur'an to alleviate psychological distress (Loewenthal, Cinnirella,

Evdoka, & Murphy, 2001). In addition to personal religious coping Muslims also consult

persons perceived to have religious authority such as the religious leader at the local

mosque, or an individual known for extensive knowledge of the religion, and culturally

recognized traditional healers. Due to the collectivistic nature of Islam, Muslims seek

help from a psychologist as a last resort: the individual may attempt self-treatment

(including prayers, meditation, reading religious texts), consult a trusted family member

or friend, or seek the help of their local masj id/mosque leader (Imam) to help resolve

psychological concerns (Mahmood, 2006).

Islam takes a scientific view of both psychological and medical illnesses.

Psychological illness is as legitimate as medical illness and seeking treatment is

encouraged, however psychological illness is greatly stigmatized in Muslim cultures. In

addition to the stigma attached to psychological illness, Western psychotherapy can be

incongruent with the beliefs and values espoused by Muslims. Western psychotherapy

focuses on the individual and ignores the collectivistic values espoused by Muslims
 32

(Haque-Khan, 1997). Additionally, psychotherapy aims to rationalize guilt whereas

Muslims believe in seeking repentance. The individualistic nature of Western

psychotherapy ignores the Islamic emphasis on social responsibility, and the belief that

the society's betterment is achieved by being selfless, and altruistic. Despite the

incongruities between Western psychotherapy and Islamic values, mental health care

professionals in predominantly Muslim societies support and advocate psychotherapy as

a valid and beneficial treatment modality (Haque, 2004).

Seeking psychotherapy carries a strong stigma for Muslims due to a combination

of religious and cultural perceptions of mental health services (Kobeisy, 2004). Muslims

may avoid using psychological services even when it becomes imperative to do so for a

personal or a mental health crises which they are experiencing, as reaching out for help

implies that they are not living in accordance to Islamic guidelines (Ali, 2006). American

Muslims, like other minority groups in the country may not be aware of the nature and

extent of health care services available to them (Kobeisy, 2004). Barriers to

psychotherapy might be as simple as not possessing knowledge of the nature of

psychological services. Although Muslim clients are less likely to access psychological

services they do engage in more informal forms of counseling, such as, seeking advice

from respected elders, Imams and teachers (Kobeisy, 2004).

Several misconceptions about psychotherapy exist within the Muslim community,

which create barriers to help-seeking. Barriers to help-seeking include: Muslims are

likely to equate seeking counseling services with being mentally ill; counseling is seen as

a threat to one's status and autonomy; seeking outside help will be viewed by self and

others as lacking the support of family and friends; lack of information about counseling
 33

and psychotherapy will contribute to viewing the counseling and psychotherapy process

with suspicion; and the Muslim client will be distrustful of the psychologist or

counselors' values and feelings, and regard the health care provider with suspicion. It

therefore, becomes important for mental health care professionals to engage in outreach

and to work collaboratively with local Muslim organizations to remove misconceptions

about psychological services, which in turn will help eradicate current barriers towards

seeking psychological help (Kobeisy, 2004).

American Muslims seeking psychological services more often than not do so

upon the encouragement of a friend, family member, or respected individual (Kobeisy,

2004). Among American Muslims, educated individuals and those who have converted to

Islam, or were born and raised in the USA are more likely to seek psychological

treatment (Kobeisy, 2004). Kelly, Aridi, and Bakhtiar (1996) surveyed 121 highly

educated and religious American Muslims' universal (for instance: benevolence, self-

directions, conformity, achievement) and mental health values (such as: positive human

relatedness, spirituality, autonomy, forgiveness) utilizing specific universal values and

mental health values inventories. Participants were primarily recruited from American

Muslim college student associations, and community members attending Friday prayers

at local Mosques in the Washington DC area. Their findings revealed that over half

(52.9%) of the participants would prefer to work with a Muslim counselor, but 43.8% of

the respondents would consider working with a non-Muslim counselor if (s)he has an

understanding of Islam and Islamic values.

A recent study examining the help-seeking attitudes of American Muslims

attempted to describe ethnic variation in help-seeking attitudes and also attempted to

 34

determine the need for and actual utilization of counseling among Muslims in Toledo,

Ohio (Khan, 2006). The study used a cross-sectional design and was quantitative in

nature. Participants were recruited from area mosques in the Toledo, Ohio area and were

asked to complete a short survey consisting of an attitudes towards help-seeking scale,

and a demographic questionnaire. Results indicated that Muslim women were more likely

to endorse positive attitudes towards counseling, and to indicate the need for counseling

than were men. An analysis of South Asian American participants in the study revealed

that South Asian men were 2.7 times more likely than South Asian women to express

negative attitudes about help-seeking, and were 3.8 times more likely to state that they do

not need counseling. Results from the overall sample which consisted of African

Americans, Arab Americans, South Asian Americans, and Others (primarily Turkish and

European Americans) indicated that the majority held positive attitudes towards

counseling. Older participants (45 years and above) were more likely to endorse use of

counseling services than were younger participants (18-44 years old). Discrepancy

between the need for counseling and actual use for it was also noted. Khan (2006) notes

that 15.7% of her sample indicated the need for counseling but only 11.1% had used

services in the past two years. Forty-nine of the 72 participants who indicated the need

for counseling had not utilized services in the past 2 years.

This discrepancy could be due to the lack of knowledge and awareness about

counseling among the American Muslim community, or could imply that American

Muslims choose other sources of support rather than professional counseling. Khan's

(2006) data supports this fact as the participants of the study identified prayer, reading the

Qur'an and seeking family support, and resources in their community as primary means
 35

of coping. Additionally Khan (2006) also identified ethnic group preferences for coping,

including the preference of South Asians to seek help via multiple modalities. Khan's

(2006) study is valuable in contributing to the scarce literature on American Muslims. It

is also unique in that she attempted to analyze ethnic differences among American

Muslims.

Most of the research focusing on South Asian women has been conducted in

Great Britain and Canada. Many of the studies have ignored the impact of religion in the

lives of South Asian women, several of which are reviewed in the following section. In

literature where religion is identified, it is mainly done so as a demographic variable.

Psychological Health Concerns of South Asian Muslim

Women

Research on British South Asian women reveals that South Asian women

experience greater levels of psychological distress (Williams & Hunt, 1997), and have

higher prevalence rates for depression, suicide, deliberate self-harm, and eating disorders

(Anand & Cochrane, 2005). British Pakistani Muslim women have been identified as

being vulnerable to suffering from depression and anxiety (Hussain & Cochrane, 2003).

Williams and Hunt (1997) assessed for psychological distress among British

South Asians by utilizing a general health questionnaire, a psychosomatic symptom scale,

and a self-assessment of levels of distress. Participants were from a community sample

and were recruited from the Glasgow area. The results of this quantitative study indicated

that South Asians experience higher levels of psychological distress than other ethnic

groups in Britain. Women, Muslim South Asians, and South Asians with limited English

language proficiency reported the highest levels of distress. An explanation of the

 36

increased distress experienced by these groups is due to the situations they experience,

including systemic issues such as classism and racism, acculturation and adjustment

issues, and the loss of extended family support. Williams and Hunt (1997) noted that

British Muslim South Asian participants had the highest level of self-assessed distress.

Approximately 52% of Muslim women and 45% of men endorsed being highly

distressed. One limitation of this study is that all of the participants resided in the

Glasgow area of Scotland. A replication of this study with South Asians residing in other

parts of Great Britain is needed to assess if the levels of psychological distress

experienced is similar to or different from residents of Glasgow. Additional studies with

European South Asian Muslims, and with South Asian American Muslims are also

needed to compare the similarities and differences in the experience of this population in

the Western diaspora, and to identify the factors that contribute to psychological distress.

Ahmad, Shik, Vanza, Cheung, George, & Stewart (2004a) interviewed 24 South

Asian women who were recent immigrants to Canada. Focus groups were conducted with

the participants. The authors do not detail the protocol utilized, and only state that open-

ended questions were utilized to guide discussion. The results of this particular

qualitative investigation highlighted mental health as a major health concern for these

women, which were defined in somatic terms. Ahmad et al (2004a) detailed that these

women were struggling to adjust to a new society and lacked information about accessing

health care services, or did not have health care benefits. The participants also stated that

mental health concerns became an issue post-immigration.

In another qualitative investigation Ahmad, Shik, Vanza, Cheung, George, &

Stewart (2004b) conducted focus groups in which discussion was guided by open-ended
 37

questions with recent South Asian immigrant women the results of which also indicated

that mental health concerns were of primary importance post-immigration. South Asian

women tended to view mental health in holistic terms and information regarding health

was obtained primarily through social networks and community centers. Barriers to

accessing health services included language ability, the loss of pre-immigration social

networks, access to transportation and work demands (Ahmad et al., 2004b).

The focus group research qualitative methodology of these studies yielded rich

data, but limits generalizability due to small sample sizes. The methodology for the

studies is not explicated beyond informing the reader that it is a qualitative methodology

utilizing focus groups. Additionally all of the participants had lived in Canada for five

years or less. Thus, the experience of these participants is likely to differ from immigrants

who have lived in Canada or the United States for several decades, and from women who

are first generation Canadian or American South Asian Muslims. Qualitative research

seeking to investigate the meaning of psychological health and wellbeing, the

psychological concerns, and help-seeking attitudes and behaviors of first generation

South Asian Muslim American and Canadians, and South Asian immigrants who have

been settled in North America for several decades is needed to develop a deeper

understanding of this population. Considering that a substantial portion of the South

Asian American population immigrated soon after the passing of the 1965 immigration

act, members of this sub-group have spent the majority if not all of their lives in America.

Fenton and Sadiq-Sangster (1996) explored South Asian women's definitions and

perceptions of mental distress in England. Approximately sixty-five percent of the

participants were Muslim women. The sample consisted of women who were recent
 38

immigrants and those who had been in England for over 10 years. This was an

anthropological study employing qualitative methodology. Participants were recruited

from local health and community centers. Thirty-three women participated in structured

interviews that explored their perceptions of health and illness, experiences with health

care, as well as other aspects of daily life. Ten participants were interviewed in a

relatively more open-ended and informal manner. Many interviews were also conducted

as informal extended conversations in natural settings with the participants. The majority

of interviews were audio-recorded. The participants described mental illness in holistic

terms and distinguished between thinking in one's head versus thinking in one's heart

(Fenton & Sadiq-Sangster, 1996, p.76). Thinking in one's heart appears to connote

feelings of psychological distress. Additionally the participants felt that they could not

seek treatment for psychological distress as there is no doctor's cure for it. This

qualitative study provided valuable information pertaining to the definitions ascribed to

mental illness, and perceptions and efficacy of treatments. This research highlighted the

influence of cultural context on the definitions and perception of mental illness, and

underscored the value of conducting qualitative research.

Another qualitative study utilizing focus group discussions was conducted in

England by Chew-Graham, Bashir, Chantler, Burman, & Batsleer (2002) aimed to

identify the psychological needs of South Asian women residing in Britain. Notes were

taken by the facilitators during the focus groups and were later analyzed to identify

emerging themes or issues that contributed to mental distress. Participants were recruited

from the South Asian community and focus groups were conducted in several locations

including two organizations for South Asian women, a women's community health
 39

center, and a young women's group center. Discussion was primarily guided by group

discussion, and the facilitator followed a flexible group protocol in order to include

questions regarding understanding mental distress, issues and concerns regarding self-

harm, and attitudes towards existing health care services. All participants except one were

Muslim. Findings from this study identified several issues of concern to this population.

Some of these issues included systemic concerns (including social, political and

economic pressures), domestic violence, poverty, English proficiency, concern for family

and children's health and wellbeing. Another concern among this community is domestic

violence, and the strong stigma in the South Asian community against divorce even if a

woman is in a domestic violence situation. Self-harm was identified as a coping strategy

and women tended to access psychological services only in a crisis situation rather than

as a preventative measure or prior to the escalation of distress. The acknowledgement of

self-harm as a coping strategy is not surprising as even in the USA the suicide rate is high

for young Asian women (Chew-Graham et al., 2002). Barriers to help-seeking identified

by the participants included concerns about the maintenance of confidentiality,

specifically not wanting others in the community to know that they were seeking

psychological help. Additionally distrust of mainstream providers was expressed.

Chew-Graham et al. (2002) advocated for developing support groups for South

Asian women, and the need to do more outreach work with this community. A detailed

list of recommendations for improving services for South Asian women was also

provided in the article (Chew-Graham et al., 2002, p. 346). Recommendations included

being aware of and acknowledging cultural differences in the expression of psychological

distress, and also being sensitive to the systemic issues faced by British South Asian
 40

women. It is sobering to note that Chew-Graham et al (2002) mentioned high rates of

suicide among South Asian American women. This indicates that South Asian American

women experience psychological distress, and also calls for the need for more research to

determine the factors contributing to this distress as well as resources accessed to cope

with distress.

Barn and Sidhu (2004) conducted in-depth semi-structured interviews and focus

groups with Bangladeshi Muslim women in Britain in order to understand the

intersections between social class, ethnicity, gender, and health, and to explore the

definitions of health, identification of social care needs and concerns, and perceived

barriers to accessing health and social services. The authors did not identify an interview

protocol, and only stated that the guiding questions for the focus groups and interviews

were based upon previous research literature available on this particular population.

Women were recruited from voluntary community organizations and via informal

networking. Similar to other studies on South Asian women Barn and Sidhu's (2004)

findings confirmed that Bangladeshi Muslim women view health holistically, and express

psychological symptoms somatically. Barn and Sidhu (2004) imply that the

"compartmentalized nature of service delivery" (p. 21), is at odds with the holistic view

of health held by Bangladeshi women and hinders service utilization. This particular

qualitative study reveals that socioeconomic status is the primary factor adversely

affecting the health status and access to services for Bangladeshi women. The main

source of support identified by participants was turning to religion, coping individually

through religious practices and turning to Imams and traditional healers for support. The

cultural and historical context of Bangladeshis in Britain suggests that this minority is a
 41

target of racial harassment and attacks, and tends to be economically disadvantaged (Barn

& Sidhu, 2004). All of these factors contribute to the psychological distress experienced

by members of this particular community. Barn and Sidhu (2004) 's study is the sole

study reviewed in this section that calls attention to the importance of social class in

affecting mental health status. Future research with South Asian women in the Western

diaspora needs to explicitly examine the impact of social class on psychological

wellbeing.

Haque-Khan (1997)'s unpublished dissertation is one of the few studies

examining the perceptions of mental health among American Muslim women. She

utilized a mixed methods design to explore American Muslim women's perceptions of

mental health, and the contribution of acculturation and religion in developing these

perceptions. Almost half of Haque-Khan (1997)'s sample identified as South Asian

American, hence the results obtained from this study are of relevance to South Asian

American Muslim women.

Forty-two women participated in the quantitative component of the study. The

quantitative component was composed of a demographic information form, Islamic

religiosity measure, American International scale, and an attitudes towards help-seeking

inventory. Eighteen women participating in the quantitative portion of the study were

first generation American and twenty-four were immigrants. Of these forty-two women

eighteen women participated in the qualitative component of the study. Nine of these

participants were first generation American and nine were immigrants. Eighteen women

who participated in the quantitative portion of the study identified their country of origin

in South Asia. Six women identified their home country as USA or Canada; hence their
ethnicity could not be determined. The qualitative component consisted of semi-

structured interviews, and focus groups that discussed case scenarios. Data was analyzed

by reviewing transcripts for emergent themes. Quantitative results showed no differences

in attitudes towards help-seeking between immigrant women and first generation

American Muslim women, or between those who were highly religious versus not as

religious. Results did indicate that women who were highly acculturated to American

culture expressed more positive attitudes towards help-seeking than those who were low

on acculturation (Haque-Khan, 1997). Women perceiving low levels of prejudice were

more likely to have positive attitudes towards help-seeking, as were those who were

proficient in the English language.

The results of the qualitative portion of Haque-Khan's (1997) study

complemented and clarified the quantitative findings. Nine of the eighteen women

interviewed identified as South Asian. Both immigrant and first generation Muslim

women identified religion as a coping strategy. Immigrant women identified problems

facing the Muslim community including: generational problems, negotiating bi-

culturality, marital problems, and abuse. Participants stated that these problems are

partially present due to lack of education and knowledge, as well as lack of experience of

living in American culture (p. 121 and 202). First generation Muslim women identified

problems in the Muslim community as falling under the umbrella of intergenerational

communication problems. Both groups of women (immigrant and first generation) would

consider seeking help for their concerns, however the type of help sought was dependent

upon the nature and severity of the problem. The preference among the participants was

to seek advice from a friend, family member or a respected elder. General distrust of
 43

Western professionals was expressed, and participants felt that the Western professional

would not have an understanding of their religious and cultural beliefs and values.

Although several women indicated seeking help within the religious community via the

Imam, first generation women felt that the Imam would be unable to understand their

concerns. This is a valid concern for first generation Muslim women as the majority of

Imams in the United States are recent immigrants and thus may not be sensitive to the

conflicts and stressors faced by American Muslims. First generation women did state that

they would prefer to seek help from someone within their community thus indicating a

need for ethnically and religiously similar mental health professionals.

All of the women were asked to identify problems of minor, moderate and severe

concerns in order to specify when they would consider seeking professional help. Women

identified personality disorders, divorce, domestic abuse, suicidal behavior, religious

identity confusion, and pre-marital sexuality as severe problems for which psychological

help needs to be sought. Only first generation American Muslim women identified the

latter three issues. Participants expressed stigma attached to seeking psychological help,

specifically being labeled by others if found out that they were seeking help for

psychological concerns. Participants who had previous direct or indirect experience with

counseling and psychotherapy generally had more positive attitudes towards help-

seeking.

Some recommendations and implications from Haque-Khan's (1997) study

included acknowledging the collectivistic culture within the American Muslim

community. Reliance on friends and members of the community for support suggests that

facilitated self-help groups may be beneficial for American Muslim women. Additionally
 44

outreach efforts need to be increased to this community to enhance their knowledge and

awareness of psychological services. Implications for psychologists included learning

more about the religious and cultural beliefs of the American Muslim community, and to

develop an understanding of the conceptualization of mental health and illness, as well as

knowledge of some of the problems that American Muslim women identified as being

faced by their communities. Collaborating with respected community leaders so that they

may refer others to seek psychological services will also help remove some of the barriers

to help-seeking.

Haque-Khan's (1997) mixed method analysis of the perception of psychological

health among American Muslim women provides valuable information and

recommendations for the health care provider. Limitations of the study include its mixed-

method methodology. Only 42 participants provided data for the quantitative component

of the study. A larger sample size is needed to strengthen the quantitative section of the

study. Rich data were obtained from the qualitative component of the study and provided

an introduction to the concerns of American Muslim women. Future studies ought to

focus on specific ethnic and cultural subgroups of the American Muslim community in

order to determine similarities and differences between the subgroups. Follow-up studies

would also provide information on similarities and differences in the perception of

psychological health and wellbeing and ethnic and cultural specific attitudes and

behaviors towards help-seeking.

The literature reviewed above identified psychological health concerns of

relevance to South Asian American Muslim women, in addition to providing information

about the help-seeking attitudes of this population. In the following section a brief
 45

overview of the psychological health concerns of South Asian American Muslim women

is provided.

Summary

The review of literature suggests several clinical and research implications that

need to be taken into account when considering this population. These implications as

identified by the literature are summarized in this section.

Many psychologists hold stereotypes of South Asian women (Burr, 2002) which

can be addressed by increasing knowledge and awareness about the South Asian culture

and its values. Similarly, psychologists would benefit from taking advantage of

educational opportunities, which address religious beliefs, and values of Muslims.

The South Asian American Muslim community views health and wellbeing

holistically. Psychologists should acknowledge their client's holistic view of health and

take this into consideration when choosing an intervention, as interventions that

compartmentalize problems may do more harm than good.

In order to gain trust of the community and to establish credibility the

psychologist should collaborate with community leaders and provide psycho-educational

outreach programs in addition to informally interacting with the community at various

events to increase awareness of psychological services. Psychologists can also offer

training to religious leaders whom community members usually approach with

psychological concerns. This training can help religious leaders to identify psychological

concerns, provide them with tools to deal with conflict resolution, as well as how to

provide appropriate referrals to psychologists and other mental health care providers in

the community. Finally, considering the distrust expressed towards out-group members
 46

and the increase of this distrust post 9/11 efforts need to be made by training programs to

recruit future psychologists and other mental health care providers from the South Asian

American Muslim population.

There is clearly a lack of research on South Asian American Muslim women.

Existing research fails to examine the intersection of religion and culture in the lives of

South Asian women. Researchers acknowledge that religion plays an important role and

recommend that this area be further explored. In order to learn more about this population

researchers should consider employing qualitative methodology, as the benefits of

conducting qualitative research with a population on which data is scarce are numerous.

Qualitative research provides rich data on the life experiences, as well as

problems and concerns faced by South Asian American Muslim women. Researchers can

use qualitative methodology to learn about the women's definitions of psychological

health and wellbeing, as well as their attitudes and beliefs towards help-seeking,

including resources which are accessed to cope with psychological concerns, and barriers

to accessing other resources. The gap in research of the religion-culture intersection can

be addressed by including questions about the role that religion plays in their lives,

especially with regards to coping with psychological concerns.

Learning about South Asian American Muslim women's definitions of

psychological health and wellbeing, the intersections of religion and culture, and the

perceptions of and attitudes towards psychologists and other mental health care providers

will inform clinical work. Finally, this information will also provide directions for future

qualitative and quantitative research by identifying specific issues that are of importance

to this population.
 The Current Study

The review of literature illustrates the need for research with South Asian

American Muslim women. Research exploring this population's definitions of, and

attitudes towards help-seeking would be valuable. In the review of literature, help-

seeking has been defined through Western lens, that is, seeking out a mental health

professional (e.g. psychologist, social worker, counselor). This traditional definition of

help-seeking is culture-bound and fails to take into account alternative resources that may

be accessed by South Asian American Muslim women when experiencing psychological

distress (for instance, seeking family support, consulting a religious or spiritual leader).

Due to limited research on South Asian American Muslim women a qualitative

investigation inquiring about the definitions of psychological health and wellbeing, and

attitudes towards help-seeking is warranted. Qualitative research is advantageous when

there is limited information available on a certain population or phenomenon of interest

(Hill, Thompson, & Williams, 1997). Additionally, data collected in qualitative

investigations consists of words rather than numbers, and thus is rich in the information

yielded. Participants are not limited in their responses, for instance, choosing from a set

of responses in a quantitative investigation. The rich data yielded in qualitative

investigations allows for the determination of a range of possibilities (e.g., different

definitions of help-seeking, the multiple ways in which religion and culture intersect) that

can assist in the development of a quantitative study to confirm the results of the

qualitative investigation, and determine the generalizability of the results to this

population at large (Hill et al., 1997). Data from qualitative investigations also informs
the development of psychometric scales (for instance, an attitudes towards help-seeking

scale specific to the South Asian American population).

Many of the empirical studies on South Asian women that have been referenced

thus far have employed qualitative methodologies. However, only three of these studies

identified the specific qualitative methods and paradigms within which the investigation

was conducted. These included a grounded theory approach within a constructivist

paradigm (Hussain & Cochrane, 2002, 2003), and critical ethnography (Hilton et al.,

2001). Other qualitative studies reviewed did not identify a particular methodology or

paradigm within which the investigation was located when describing the research

methodology (Ahmad et al, 2004a; Ahmad et al, 2004b; Barn & Sidhu, 2004; Fenton &

Sadiq-Sangster, 1996; Ross-Sheriff, 2001; andNAWHO, 1996). The lack of emphasis

placed on defining the research methodology, in addition to the tremendous variation in

the methodologies employed by previous qualitative studies mentioned above is clearly a

limitation of the research literature. Qualitative research has been criticized for lacking

rigor and consistency (Hill et al., 1997), and thus, it becomes important for the qualitative

researcher to conduct a methodologically sound investigation. This dissertation study

employed consensual qualitative research (CQR), a methodology developed to address

this criticism (lack of rigor and consistency) of qualitative research (Hill et al, 1997, Hill,

Knox, Thompson, Williams, Hess, & Ladany, 2005). Paradigmatically CQR leans

towards postpositivism with some constructivist influences (Ponterotto, 2005). The

philosophical basis of CQR, and research procedures are elaborated upon in Chapter 3.

CQR has been selected for the current study due to its well-defined research

methodology, and because it is an inductive method where conclusions are generated

from the data collected rather than apriori (e.g. via specific hypotheses that need to be

confirmed). Although the end goal of CQR is to identify one "true" reality it allows for

the expression of multiple perspectives, of the participants (via interviews), as well as the

primary research team members (during data analyses).

The current study employed CQR in order to investigate the definitions of

psychological health and wellbeing, and attitudes towards help-seeking among South

Asian American Muslim women. This study also sought to investigate the intersections

between religion and culture pertaining to the perceptions of psychological health and

wellbeing as well as the impact one's religiocultural identity has upon help-seeking.

Overall the current study aimed to investigate the definitions of psychological health and

wellbeing and attitudes towards psychological help-seeking among South Asian

American Muslim women and the influence of religion and culture upon these definitions

and attitudes. The primary research questions guiding the current study were:

1. How do South Asian American Muslim women define psychological

health and wellbeing? What role does religion and culture play in

forming definitions of psychological health and wellbeing?

2. What are some psychosociocultural concerns experienced by South

Asian American Muslim women?

3. What are the attitudes towards help-seeking and what resources are

accessed in order to alleviate psychological distress?

 CHAPTER 3

METHODOLOGY

This chapter describes the methodology and research design of the current study.

First the CQR methodology for the current qualitative investigation is defined, followed

by a description of the participants, measures and procedures used by the researcher to

identify and recruit participants and collect data. Finally, data analysis procedures in

accordance with CQR methodology are presented.

Consensual Qualitative Research

CQR is a relatively new qualitative methodology that was postulated by Hill et al.

(1997) and was recently updated (Hill et al, 2005) after the authors reviewed a corpus of

research studies that utilized CQR. The current study followed the updated CQR

methodology as proposed by Hill et al (2005).

Typical components of CQR include: semi-structured interviews with 8-10 open-

ended questions (30-60 minutes in length); a minimum of 3 judges comprising the

primary research team to allow for multiple perspectives; 8-15 participants; reliance on

consensus among the primary research team in order to make meaning of the data; at

least one auditor; identification of domains, core ideas and cross-analysis (Hill et al,

1997, Hill et al., 2005). These components will be expanded upon as the procedures are

described.

CQR is a collaborative approach as evidenced by the emphasis placed on

consensus. The inclusion of at least three members on the primary research team who

participate equally in conceptualizing the interview protocol and analyzing data, and the

acknowledgement that participants are experts on their own experience emphasizes the
 51

collaborative and feminist nature of CQR. CQR allows for the expression of multiple

perspectives through its emphasis on words rather than numbers, the development of

domains and core ideas that often times present differing views expressed by the

participants, thus yielding a richer understanding of multiple realities. CQR is grounded

in a postpositivist paradigm with constructivist influences (Ponterotto, 2005). The

theoretical underpinnings of CQR are elaborated below.

Theoretical Basis of CQR

The CQR approach is based upon phenomenological theory, grounded theory and

comprehensive process analysis (Hill et al. 1997, Hill et al, 2005, Ponterotto, 2005). The

method was originally developed by counseling psychology researchers in order to

incorporate constructive methodology with postpositivism (Ponterotto, 2005), and to

develop a qualitative methodology that could be consistently followed by researchers

(Hill et al., 1997). Postpositivists seek to acknowledge a common reality whereas

constructivists acknowledge the presence of multiple equally valid realities (Ponterotto,

2005). Hence, CQR with its acknowledgement of multiple realities but emphasis on

seeking out commonalities to create an approximate reality falls between the framework

of postpositivism and constructivism.

Ponterotto (2005) anchored CQR to the philosophy of science by identifying the

research paradigms CQR methodology fall in with regards to ontology (nature of reality),

epistemology (relationship between participant and researcher), axiology (researcher's

values and biases), rhetorical structure (language use), and methodology (data collection

and analyses).
 52

With regards to ontology CQR is primarily constructivist in that, there is the

recognition of equally valid multiple realities, however there is an emphasis on seeking

out the commonalities in the data to create one constructed reality (Hill et al., 2005,

Ponterotto, 2005). In terms of epistemology CQR incorporates constructivist and

postpositivist elements (Hill et al, 2005, Ponterotto, 2005). This is illustrated by semi-

structured interviews that are informed by the literature review, but allow for additional

probing and include open-ended questions. The acknowledgement of researcher biases

and expectations places the axiology of CQR between the constructivist and

postpositivist paradigms (Hill et al., 2005). The acknowledgment and discussion of

researcher biases is derived from constructivism, whereas the emphasis on keeping a

check on these biases so that results are not influenced is primarily postpositivist (Hill et

al., 2005). The rhetorical structure of CQR includes constructing commonalities by

identifying domains and core ideas from the data collected, however the participants'

voice is also acknowledged by using the participants' voice (see Ali, Mahmood, Moel,

Hudson, & Leathers, 2008; Juntunen, Barraclough, Broneck, Seibel, Winrow, & Morin,

2001; Knox, Burkard, Johnson, Suzuki, & Ponterotto, 2003; and Schlosser, Knox,

Moskovitz, & Hill, 2003). Hence, the rhetorical structure of CQR incorporates

postpositivist and constructivist elements. The methods employed by CQR to collect data

(that is, the interviews), and data analysis also fall somewhere between postpositivism

and constructivism (Hill et al, 2005, Ponterotto, 2005). Overall, CQR contains elements

of postpositivist and constructivist paradigms.

 53

Rationale for using CQR

CQR was an appropriate methodology for the current study as it allowed for the

examination of the multiple perspectives of South Asian American Muslim women and

their definitions of psychological health and wellbeing, and attitudes towards help-

seeking. Additionally, information regarding the various ways in which religion and

culture intersect for South Asian American Muslim women with regards to help-seeking,

as well as definitions and identifications of psychological health concerns were also

obtained. The collaborative nature of CQR, and the respect for research participants (that

is, participants are experts on their experiences), reduces barriers in recruiting

participants. Additionally CQR is an ideal methodology for the current study as the study

is explorative in nature, that is, it seeks to obtain definitions and meanings assigned by

the population of interest to help-seeking.

Previous studies have also utilized CQR for this reason, that is, the meanings and

definitions assigned by the population of interest to certain phenomena and experiences,

for instance meaning of career related concepts for American Indians (Juntunen et al.,

2001), graduate advisee's perspectives on graduate advising relationships (Schlosser et

al., 2003); relationships between constructs, for instance, the impact of religious beliefs

on feminist identity for Muslim and Christian women (Ali et al., 2008), and addressing

race in cross-racial psychotherapy dyads (Knox et al., 2003). Next, details regarding

research procedures for the current study are explicated.

 54

Participants

Interviewees

The criteria for participation required the participants to have resided in North

America for all if not most of their lives, identify as South Asian and Muslim, and be

between 20-35 years of age. Participants were recruited via personal networks (i.e. via

South Asian Muslim acquaintances), sending announcements over University and

community e-mail listservs (for instance, the Muslim Students Association listserv, the

Albany Muslims listserv, and the Muslim American Society listserv), and by posting

fliers at the local mosque and Islamic center (for example, the Islamic Society of Tampa

Bay). The age range for the participants was determined by the age group categorizations

on demographic surveys, however a lower age limit of 20 was decided upon in order to

ensure that the participants were not currently enrolled in high school. Participant

recruitment was geographically limited to Tampa, Florida, and the Albany, New York

regions. The primary investigator was residing in Tampa, Florida during the data

collection phase of the study, and also had an established relationship with the Albany,

New York's Muslim community, hence facilitating participant recruitment. The study

was advertised as investigating the perceptions and attitudes of South Asian American

Muslim women towards seeking help for mental health concerns (see Appendix A). All

participants were screened via phone, e-mail, or in-person by the primary researcher to

ensure that they met the study criterion (see Appendix B). Participants were informed that

the interview will last for approximately one hour, will be audio-taped, and will be

completely confidential. An informed consent form detailing this information was

provided to the participants (see Appendix C).

 55

Pilot interviews were conducted with two South Asian American Muslim women.

One woman was a 32 year old married woman with an infant and the second interviewee

was a single, 23 year old recent college graduate. The primary investigator conducted the

first pilot interview, whereas the primary investigator and a member of the research team

were both present for the second pilot interview. The purpose of the pilot interviews was

to review the structure of the interview and to solicit feedback on structuring and wording

the interview so that it maintained the flow of conversation and would be easy to

understand by the participants. The participants suggested that interviewers consistently

use both psychological and emotional health and wellbeing when asking questions, this

suggestion was made by the first pilot interview participant who stated that some

participants may relate better to emotional health and wellbeing as using the term

'psychological' felt more academic. However, she also indicated that most participants

would understand the meaning of psychological health. Additionally, the second pilot

interview participant felt that an introductory question was needed at the beginning of the

interview to facilitate rapport building, and to inform participants of what to expect from

the remainder of the interview. Both participants had difficulties answering questions that

inquired about concerns and issues being faced by their religiocultural community for

instance: "What types of problems/concerns issues that you or others of your

religiocultural background have faced/are facing?" Both of the participants expressed that

the wording was somewhat awkward and thus based on their suggestions the question

was reworded to "Are there concerns you've noticed coming up for yourself, your family,

your friends or others in your cultural group (e.g. Indian American), regarding their

psychological health? Are these concerns/issues similar to one's experienced by members

 56

of your religious group?" The preliminary interview protocol for the pilot interviews can

be viewed in Appendix D, and the final protocol including the demographic form is

attached in Appendix E. Following revisions to the interview protocol based on the

feedback provided by the participants of the pilot interviews, and discussion amongst the

primary research team, a total of thirteen South Asian American Muslim women were

recruited to participate in the study.

Thirteen South Asian American Muslim women between the ages of 20-34

(M=25.46, SD= 4.61) participated in this study. Participants were primarily recruited

through email listserv announcements and personal networking. All of the participants

identified as Muslim. Ethnically seven participants identified as Pakistani, two identified

as Bengali, two identified with both their Pakistani and Indian heritage, and two

identified as Indian. All of the participants added American, with two also identifying as

Canadian-American to their ethnic/cultural identity. Seven participants were single, four

were married, and two were in a relationship. All four of the married participants had

children. Eight participants identified as students, five were currently pursuing their

undergraduate degrees, and three of the participants were currently pursuing graduate

degrees. The remaining five participants all had undergraduate degrees, and two of these

participants had master's degrees. Three participants identified themselves as

homemakers, however one of these participants also identified herself as a student, and

another identified as a "homeschool mom." Two participants were working for not-for-

profit organizations and one was currently working temporarily in a secretarial position.

Participants used the social class ladder to indicate their social class status in society,

based on the 10 rungs of the ladder (Adler, Epel, Castellazzo, & Ickovics, 2000). The
 57

tenth rung of the ladder indicates membership in the top-most social class, or those that

are best off in society. The majority of the participants fell into the upper-middle half of

the ladder (M=6.3, S.D. 1.7). Based upon the social class ladder participants identified as

being middle or upper-middle class. For a complete listing of demographic information

see Table 1.

Research Team

The primary research team consisted of three female judges. The primary

investigator identified as South Asian American Muslim, one judge identified as

European American, and the third judge identified as an African American Christian. The

primary research team members were 28, 31, and 27, respectively when the study was

conducted. At the beginning of the study the primary investigator was a pre-doctoral

intern, the second judge was transitioning into her first postdoctoral position, and the

third judge was in the sixth year of her doctoral program. All of the judges had previous

experience in the CQR methodology. A 29 year old, biracial female in her fourth year of

doctoral program served as the external auditor for this study. The external auditor was

provided information on the CQR methodology and her role and responsibility as the

auditor by the primary investigator. The judges and the auditor attended or were a recent

graduate of the same Counseling Psychology doctoral program.

Researcher Biases and Expectations

The primary research team discussed biases and expectations prior to data

collection and journal entries were kept prior to and after the completion of each

interview in order to record reflections and track biases and expectations of the

researchers. Prior to data collection one of the researchers expected that participants from
areas with large South Asian American communities would rely on more traditional

methods of help-seeking such as relying on superstition, and turning to traditional healers

and religious leaders for assistance in coping with stressors. In terms of definitions the

researchers' assumption was that the participants would take a holistic mind-body view

of psychological concerns/issues. The researchers also expected that participants would

be reluctant to seek out the services of psychologists and other mental health care

professionals.

Measures

Demographic Form

All participants filled out a demographic form (see Appendix E) that inquired

about their age, racial/ethnic background, length of stay in the USA, educational

background, household income, marital status, religious identification (e.g. whether they

identify with a particular sect of Islam i.e. Shia, Sunni etc.), number of people residing in

their household, number of children (if any), current occupation, and subjective self-

report of their social class status via the social class ladder (Adler et al., 2000) (see Table

The demographic form also included three short assessment instruments to

provide a description of the participants' adherence to cultural values and their level of

religious identification. These included the Asian Values Scale-Revised (AVS-R) (Kim

& Hong, 2004), Religious Commitment Inventory-10 (RCI-10) (Worthington, Wade,

Hight et al., 2003) and Moslem Attitude towards Religiosity Scale (MARS) (Wilde &

Joseph, 1997). Participants' responses to these instruments have been summarized in

 59

Table 2. Overall, participants exhibited a high level of religiosity, and tended to endorse

Asian cultural values. A brief description of the instruments is provided below.

Asian Values Scale-Revised:

The AVS-R is a 25-item likert scale (l=strongly disagree, 2= disagree, 3=agree,

4=strongly agree) that is designed to examine adherence to Asian cultural values and how

these values may have an impact on psychological issues and help-seeking behaviors

(Kim & Hong, 2004). The scale is specifically designed to measure adherence to Asian

values among first generation Asian Americans. 11 items from the original Asian Values

Scale (AVS) were discarded due to redundancy and lack of construct homogeneity (Kim

& Hong, 2004). 12 items on the AVS-R are reverse scored. Examples of items on the

AVS-R include "Modesty is an important quality for a person", and "Educational and

career achievements need not be one's top priority." The AVS-R has a person-separation

reliability of 0.80 comparable to the internal consistency coefficients of the original 36-

item scale for which the coefficients were 0.81 and 0.82 (Kim & Hong, 2004).

Additionally the Pearson correlation coefficient between the AVS-R and AVS was 0.93(p

= .000). Higher scores indicate strong identification with Asian cultural values. The

greatest possible sum of scores is 100 on this measure, the current sample on average

scored 60.54 with a standard deviation of 7.84.

Religious Commitment Inventory-10:

Worthington Jr. et al. (2003) developed the RCI-10 in response to a need for an

assessment instrument to measure religiosity in clients. The RCI-10 is a 10-item

instrument and uses a 5-point likert scale (1 =not at all true of me, 2=somewhat true of

me, 3=moderately true of me, 4=mostly true of me, 5=totally true of me). The RCI-10 is
composed of two factors: intrapersonal religious commitment, and interpersonal religious

commitment. The coefficient alpha for the full scale is 0.93, and the Pearson correlation

coefficient between the two factors is 0.72 (pO.OOl). The three-week test-retest

reliability coefficient for the RCI-10 was 0.87 (Worthington Jr. et al., 2003). Although

the RCI-10 has been developed primarily on Christian populations and further research

needs to be conducted on members of other religious groups the authors indicated that the

normative mean for US adults on the RCI-10 is 26 with a standard deviation of 12, and

that a score of 38 or higher is indicative of a high level of religiosity in the respondent

(Worthington Jr. et al, 2003). The mean score for participants on this measure was 39.08

with a standard deviation of 8.25. Examples of items on the RCI-10 include: "My

religious beliefs lie behind my whole approach to life", and "I enjoy working in activities

of my religious organization."

Moslem Attitudes Towards Religiosity Scale:

The MARS is a brief 14-item inventory, which uses a 5-point likert scale (1=

strongly disagree, 2=moderately disagree, 3=neutral, 4=moderately agree, 5= strongly

agree), and is specifically designed to assess religiosity in Muslims. Wilde & Joseph

(1997) based the MARS on the Francis Scale of Attitude towards Christianity, and

feedback from the local Muslim community in Exeter, England and reported an internal

reliability of 0.93 (Cronbach's alpha). Items on the MARS include: "Saying my prayers

helps a lot", "Allah helps me", and "I fast the whole month of Ramadan." Higher scores

signify a greater level of religiosity. On average the current sample scored 63.54 on this

measure out of a total of 70, with a standard deviation of 5.22.

 61

Interview Protocol

One semi-structured interview with 10 open-ended questions (see Appendix E)

lasting approximately an hour was conducted. The interview inquired about participants'

identification with their religion and culture, and the influence their religiocultural

background has on definitions of psychological health and wellbeing. Inquiries were also

made regarding definitions of psychological distress, and definitions of, and attitudes

towards help-seeking. The preliminary interview protocol was developed based on the

review of literature by the primary research team and was further refined after the two

pilot interviews had been conducted per CQR protocol (Hill et al., 2005).

Procedures

Recruiting Participants

Participants were recruited primarily via personal contact/networks, and e-mail

listservs (e.g. local Muslim community listserv, Muslim Student Association listservs).

Fliers (see Appendix A) were posted at various local ethnic grocery stores, as well as

local mosques and Islamic centers; however, this method of recruitment was

unsuccessful. Potential participants indicated their interest in participating in the study by

contacting the primary investigator via email. The primary investigator responded to the

email by informing the potential participants of the purpose of the study and eligibility

criteria for participation. If the participants met criteria and were interested in

participating the interview was scheduled via phone and/or email depending on the

participant's preferred means of communication.

Two of the potential participants who contacted the primary investigator and

indicated their interest in participating in the study were unable to do so. One of these
 62

participants was unable to find time in her busy schedule to participate in the interview,

and the second participant was extremely late to her scheduled interview and indicated

she could only stay for twenty minutes, and thus was unable to participate in the study.

The Interview Process

Interviews were semi-structured and lasted a minimum of thirty-five minutes to a

maximum of an hour and forty-five minutes. At the beginning of the interview

participants were provided with a brief explanation of the study and were asked to fill out

the informed consent (Appendix C) and demographic forms (Appendix E). Interviews

were audio-taped, and were conducted at various locations based upon the participant's

convenience. These locations included on campus at the University of South Florida,

participants' homes, local mosque, and one interview was conducted at a coffee shop.

The primary investigator, who has previous training and experience with the CQR

methodology, conducted the interviews. At the conclusion of the interview participants

were debriefed and were provided the opportunity to ask questions, provide feedback to

the interviewer and reflect on the interview itself if they chose to do so. A pre and post

interview journal recording the expectations and reflections of the interview was kept by

the primary investigator.

Transcriptions

All interviews were transcribed verbatim with the exception of minimal

encouragers (such as: uh-huh, yes, etc.). The primary investigator transcribed all of the

interviews, and listened to each tape after the transcriptions to check for and correct any

errors. The transcripts were assigned a code number (1-13). At the conclusion of the

interview participants were offered the opportunity to review their interview transcripts
 63

but none chose to do so. Participants were given pseudonyms to protect confidentiality.

Additionally, identifying information, such as names, locations, agency names were

replaced with fictitious or alternative names.

Data Analysis

The primary research team independently read and reviewed the transcripts in

order to conduct the data analysis. The research team met three times to discuss the

identification of domains, core ideas, and cross-analyses. The data analysis procedure is

described in detail in this section.

Identification of Domains

The primary research team members (judges) independently read and reviewed

transcripts of the first seven interviews and generated preliminary domains (overarching

themes or ideas). These domains were generated by the data present in the interviews as

recommended by Hill et al (2005). Following their independent work the judges met to

reach consensus on the domains. A second research team meeting was conducted to

further clarify and establish domains after reading and reviewing all 13 transcripts

independently. This meeting resulted in the identification of six domains. However,

during a third meeting to identify core ideas and categories, the research team revised the

domains to more accurately reflect the data. The final set of domains included the

following: definitions of and attitudes towards psychological health and treatment,

culture, facilitators of seeking psychological help/treatment, common

psychosociocultural concerns, and coping with psychosociocultural concerns.

 Core Ideas

Identifying core ideas facilitates the categorization of data into meaningful

groups, and participants' words are used to establish core ideas. The judges generated

core ideas for each domain independently based on their review of each interview

transcript. Judges were required to keep a record of the participant and the page number

in the transcript from which the core idea was identified. Following the independent

review the judges met twice as a group and discussed and presented the core ideas that

emerged from the data and provided explanations of their reasoning for the inclusion of

each core idea, as needed. Following the presentation the judges discussed whether they

were in agreement or needed further explanation prior to the inclusion of a core idea. If

the majority of the judges (in this case 2) disagreed on a specific core idea presented it

was discarded. This process continued until all of the judges had presented their list of

core ideas.

The core ideas were generated from the data and were also guided by the domains

that had been established. During the establishment of the core ideas judges identified the

need to establish the domain of culture, in order to better organize the data. Additionally

the domain entitled barriers to seeking psychological help/treatment appeared to be

redundant as the core ideas within the domain overlapped with those present in several

other domains such as: facilitators of psychological help/treatment, and definitions and

attitudes towards psychological health and treatment.

Cross-Analysis

Cross-analysis was conducted to further organize and clarify the data. During

cross-analysis the core ideas were clustered within domains across cases to determine
 65

categories. The judges worked independently during the initial phase of the cross-

analyses and charted their results. The judges met once in person to review and discuss

their independent cross-analyses and to reach consensus. Following the in-person

meeting the judges again independently reviewed the results to assess for consistency.

The transcripts were independently reviewed a final time by the judges with the new set

of categories to assess if any important data had been overlooked, and to identify quotes

that illustrated the categories identified.

Since the judges had met approximately three times to discuss the development of

domains, core ideas and finally the cross-analysis, the need for an additional in-person

meeting was absent. Meeting more than once assists in minimizing groupthink and gives

judges the opportunity to examine the data somewhat objectively and the opportunity to

object to the results at subsequent meetings if it appears that there is an error or lack of

consistency in the coding. Hence several meetings were beneficial for the data analysis

procedure (Hill et al., 2005).

The Auditing Process

An external auditor, to assist in further organizing and clarifying the data if

needed, reviewed the final cross-analysis, along with the interview transcripts, and

summary of the demographic information.

A female fourth year counseling psychology doctoral student at the University of

Iowa served as an external auditor for this study. The auditor was provided information

on the CQR methodology, and was provided with the interview protocol, transcripts,

summary of demographic data, and the cross-analysis and results table. As an external

auditor she provided feedback to the primary research team on the final analyses, as well
 66

as suggestions on better organizing the data, including information that needs to be

incorporated into the cross-analysis. The auditor's comments were reviewed

independently by the research team members and incorporated into the final analyses

based on consensus achieved by the primary research team. There was no disagreement

among the primary research team pertaining to the auditor's feedback. The auditor

offered suggestions for consolidating categories that represented a similar theme for

instance, in the domain of culture, the current category of "there is a denial of

psychological concerns/issues and people don't understand the need for a psychologist or

why you need to go to one" was consolidated from two separate categories after the

auditor's feedback. Similarly in the domain of common psychosociocultural concerns, the

categories of "fitting in" and "stuck in the middle" appeared to address the same concern

hence, these were consolidated into "trying to fit in and feeling stuck in the middle."

Additional comments by the auditor included minor wording changes, for instance,

adding the term "positive" into a category defining the personal definitions of

psychological health. The final cross-analysis is presented in Table 3. Final decisions on

any changes needing to be made to the data were based on the team's consensus.

Stability Check

A stability check as postulated by Hill et al (2005) was not conducted. The

stability check did not appear to be necessary as the primary research team's preliminary

analysis included only the first seven interviews, and the remaining data (6 interviews)

was incorporated at a subsequent meeting. The stability check requires that at least 2

interviews are set aside and only included after the initial cross-analysis has been

conducted to ensure that the analysis is representative of the data. Since the research team
 67

members had read and reviewed all of the transcripts independently and conducted a

preliminary data analysis with half of the data, a stability check did not appear necessary.

Additionally, the research team agreed that the external auditor would be able to identify

further inconsistencies in the data, if any.

Draft of Final Results

Participants were informed that they could request their interview transcripts.

None of the participants chose to do so. However, several participants were interested in

learning about the results of the study, and primary investigator agreed to send study

results via email (participants preferred this method of communication) to the participants

at the conclusion of the study.

 68

CHAPTER 4
RESULTS
Domains and Categories

Five domains were generated from the interviews. The domains were: 1.
definitions of and attitudes towards psychological health and treatment, 2. culture, 3.
facilitators of seeking psychological help/treatment, 4. common psychosociocultural
concerns; and 5. coping with psychosociocultural concerns. Core ideas were generated
across each domain, and these were further subdivided into categories to illustrate the
data. Results are reported in Tables 3 and 4. For this sample, in keeping with Hill et al.
(2005) 's guidelines, categories were considered general if all, or all but one cases were
represented, typical if seven to eleven cases were represented, and variant if two to six
cases were represented. In this chapter, results are presented for each domain.

Domain 1: Definitions of and attitudes towards

psychological health and treatment.
Participants provided personal and religious definitions and attitudes towards
psychological health and treatment. Personal definitions and attitudes included: a.
perceiving psychologists as helpful, important, and necessary, b. being psychologically
healthy is to be balanced and stable, c. being psychologically healthy is to handle
obstacles/solve problems, d. being psychologically healthy is to be happy, positive,
content, and at peace, e. people should seek professional help when things are bad or they
are severely distressed, f. personal experiences with a psychologist or counselor.
Religious definitions and attitudes towards psychological health and treatment included:

a. psychological health as the wellbeing of both the mind and the body, b. being at one
with Allah and seeking out Allah helps maintain psychological health and wellbeing, c.
religion encourages you to take care of your mental health.
 69

Participants' personal attitudes towards psychological health and wellbeing

typically included the recognition that psychologists are helpful, important and necessary.

Variant responses endorsed seeking professional help when severely distressed, as well as

disclosure that they themselves had sought mental health/psychological services in the

past. Zainab stated that psychologists:

.. .they work to help people be able to discuss their

problems and come to their own conclusions about what they need
to do, they are not there to judge you or to tell you what to do.
Asma agreed and furthermore commented on the link between psychological and
physical health:

I am pretty educated about it I think umm and you know

my view is actually its positive I think they can be a great resource
I think that they can be great sources of helping people cope with
even just their day to day stuff as well larger issues and umm you
know and I am someone who believes that psychological stress
leads to physical stress and I mean they are linked they go hand in
hand umm so I think that dealing with psychological stress is just
as important as dealing with physical stress so like umm a mental
health provider or seeing a psychologist is just the same as going to
your general practitioner if you are in a state of stress.
Maryam furthermore commented on the difference between psychiatry and psychology as
she stated her perception of psychologists:

...as far as psychologists I like them because they listen

more they use the talk therapy its not the first thing to give
medications like psychiatrists—I call them like you know pill
happy people they are quick to like give you the medication oh this
does not work, let me give you this, I mean they listen to you for
like two minutes and then they're like I think this is what's wrong
with you, and I don't really like that, I don't like it at all I would
rather people go to a psychologist, tell them your whole story let
them listen to you and then they can probably get a feel of, I think
this is manic depression, or I think this is leading to that, maybe I
should refer you to a good psychiatrist and tell him or her about the
situation. I mean I feel like they could kind of diagnose you in the
right direction rather than going to a psychiatrist first and then you
understand?
Although participants typically perceived psychologists positively they were less likely
to endorse seeking out professional help for psychological concerns, variantly stating that
it is okay to seek professional help only when one is severely distressed or the problem is
 70

too difficult to handle on one's own. For example, Ayesha stated that if someone feels
"oh I can't handle this then they would go" seek professional help. Alina resonates with
this view and commented:

I think if I had a big problem and really did need somebody

else to talk to about it.. .if I didn't have the support I do right now I
would go.. .to a person.. .maybe...
Six participants disclosed that they had accessed services from a mental health
professional (psychologist, counselor, social worker). Reasons for seeking services
included career concerns, depression and general environmental/situational stressors.
Several participants also stated that they were aware of friends, and family members who
have sought services from a mental health professional and disclosed that some of the
concerns included: illnesses such as bipolar, eating disorders, and/or depression.

Participants provided personal definitions of psychological health and wellbeing.

Typical definitions included being happy, content and at peace, being balanced and
stable, and participants variantly stated that the ability to handle obstacles was also an
indicator of psychological health and wellbeing. For instance Benazir defined
psychological health as:

.. .just being happy with where you are how you who you
are you know. Just being satisfied with anything like [inaudible]
it's the little things in life that are so important and I think seeing
that is what's important psychologically.
She continued to expand:

Just being happy overall I don't mean to say with umm

with whatever you have I mean you should never stop trying you
know I'm not saying that if you are at the bottom of the ladder stay
there and be happy, I don't mean that. I mean try to aim for the
best but just finding happiness in everything. While trying then to
get ahead.
Maryam discussed balance as an indicator of psychological health and wellbeing:

I guess it just means that you have a balance of your

emotions and that you don't let one emotion or other like take hold
of you like you know when you are really, really angry? And you
just can't you know stop, and you're just really angry and you
 71

lose—you know what I'm saying—Yeah. So just have a balance

and control of your emotions.
Rihanna added:

I think being psychologically happy or umm health is being

happy, and umm I guess in.. .being in difficult situations being able
to handle that, being able to handle all obstacles umm and you
know being happy with life, I think that's basically it being able to
deal with hard things and like see the good in them...
Asma provided an expanded definition to include the ability to deal with obstacles:

Umm I think for me it just means you know being at a

place where you can deal with umm maybe some of the more
negative aspects of your life in a way that is healthy. That may not
necessarily mean that you know—you personally are able to be
content and happy and satisfied all the time but if you recognize
that you are not and you have those things are you able to seek out
help? Or do you realize that you need help? Or that you know even
if it is just talking to a friend or umm going to a mental health
provider whatever the case may be I think being psychologically
healthy just means being aware of where you are mentally and
emotionally and being able to recognize when you need help in
some way, shape or form.
Participants also provided religion's definitions of and attitudes towards psychological
health and wellbeing. Participants variantly identified the importance of being at one with
Allah and seeking out Allah to maintain psychological health. Participants referred to the
mind-body connection in maintaining psychological health and wellbeing, and indicated
that religion encourages one to take care of one's mental health. Lay la stated that in
religion psychological health and wellbeing is:

All connected—with the spirit, the body, everything is

connected. You can't just like like uh be physically be happy, I
mean physically be healthy and if you are not mentally healthy it is
going to affect your body as well, it is all connected.
Zainab emphasized that religion encourages one to take care of their psychological health
and commented on the struggle between cultural and religious teachings and attitudes:

I mean Islam talks about being emotionally well and

physically well and but I think that you know we kind of get
blinded by that line between our culture and our religion so its
difficult for people to kind of separate...
Mehwish mentioned the importance of turning to Allah to maintain one's psychological
health and wellbeing:

And we have that opportunity to go to Him and ask for His

help ask for His guidance and I truly believe that His guidance is
the only thing that will get us on a straight path and the straight
direction. And really to the point where we can be—we can be
satisfied to the degree that we need to be satisfied...
Asma articulated the role Islam plays in the maintenance of psychological health and
wellbeing:

Islam I think from my study and my interpretation is very

different from the South Asian culture, fortunately. I think Islam
actually does have a very healthy outlook on psychological health
and just mental health and wellbeing. Umm for me as someone
who does pray 5 times a day I see prayer as part of, as contributing
to psychological health and it does for me at least. Umm there's
the physical aspect of taking 5 minutes out of your day a few times
a day that just kind of extracts you from whatever you know you
are dealing with and once you focus on something else it is quiet it
is meditative. I think that has enormous benefits umm I also think
to.. .that Islam as, as a social structure does have built in
safeguards for maintaining psychological health I think the fact
that its community-based umm is part of that or adds to that.
Obviously I think the application doesn't always work out that way
umm but I think the basic tenets are there you know to support
psychological health you know to support mental health and just
health in general of a community of a society and also you know of
smaller groups of individuals through that community mechanism.

Domain 2: Culture
Participants were asked to keep their cultural background in mind when
responding to interview questions, and several questions specifically asked participants to
think about community members of their cultural group when responding. During the
cross-analyses process it became evident that a separate domain of culture was needed to
illustrate the cultural definitions and attitudes towards psychological health and
wellbeing. Cultural definitions of psychological health and well-being included: a.
psychological health dependent upon family's wellbeing and expectations, b. putting on a
happy face/acting normal, c. being financially secure/stable, and d. culture does not
clearly address mental health. Cultural attitudes towards psychological health and
 73

treatment included: a. keeping psychological concerns hidden and dealing with them on
your own, b. admitting to psychological problems is seen as being weak, c. psychological
issues/illness is taboo/stigma, d. a denial of psychological concerns/issues, e. people
don't understand the need for a psychologist or why you need to go to one; and f. the fear
of shame and reputation within the community or judgment from the community.

Cultural definitions of psychological health and wellbeing variantly included

psychological health being dependent on family's wellbeing and expectations, being
financially stable, and putting on a happy face. Participants also variantly stated that
culture does not clearly address issues of mental health.
Mary am stated that culturally being psychologically healthy means:

.. .acting normal and their definition of normal is like being

happy and obedient and not showing any outbursts or anything like
that or you know not being too sad...
Rihanna discussed the role of family and culture in defining and maintaining
psychological health:

So I think being psychologically healthy is just being able

to umm you know as far as your—I guess, its just—hmm, its
keeping your family's or sorry don't know how to say it, like
living up to where your family has been and -guess that makes
sense? I don't know if I make sense. I . . .so like living up to
family's expectations sort of, or but too, I just, I think in our
culture you always have to be always have to put on a happy face
and you have to be respectful you can't really I feel like you would
have to kind of not really... like come outside, you kind of have to
fall in that narrow range, like you can't really think too much for
yourself or.. .1 think as long as you are following the same path
that everybody else is following then you are healthy but if you fall
outside of it then you are not that's what I think at least and there's
not really any room to fall outside of it.

Participants discussed cultural attitudes towards psychological health and

treatment. Typical responses included keeping psychological concerns private and
hidden, psychological concerns are viewed as taboo and are stigmatized, fear of what
would happen to one's reputation as well as concern about shame and judgment from
one's community if the community learns that one is either experiencing psychological
 74

difficulties/concerns, or seeking mental health services, and a lack of understanding of

why psychologists are needed. Maryam stated:

.. .your uncle could have depression and you won't even

know it because its all behind closed doors because they think its
such a shame such a burden they don't want anyone to know...
Maryam also referred to the stigma surrounding psychological health concerns and how
this negatively impacts health:

Oh there is a lot of stigma, there is a lot of stigma and it's

really it kinda like hurts me in a sense because there are so many
people like behind closed doors they are going through something
and they have no one to confide in and it would be so nice like if
they could openly ask for like a resource like talking to a counselor
or psychologist.
Zainab also commented on the cultural taboo of mental illness:

I think its sort of a behind closed doors type thing—I think,

I mean you know of those like aunties in the community who are
like crazy aunty you know.. .but like I don't think it really gets
addressed I think that you know people with health issues just kind
of get... 'oh, it's their personality' and it just kind of gets
overlooked and nobody wants to address the problem and deal with
it. I think it kind of stays you know within families and oh its kind
of your family secret and you are not supposed to talk to anybody
or tell anybody about it.
Neelofar suggested that this cultural stigma could in part be a result of the lack of
knowledge and understanding of psychological health and treatment:

Umm I think as soon as they see.. .hear the word

psychologist they think shrink. They think you're having a mental
breakdown and you are emotionally unstable and we need to get
you on some kind of medication and that's the end of it.. .you
know. Like I, I have a friend who does have some problems umm
emotionally and I feel that she would benefit from speaking to a
professional that has training but I know that she never will.
And.. .because she's like I will handle it myself I don't need
some—I mean in her words I don't need some quack helping me.
I'm like yeah.. .yeah you do! Because your thoughts just aren't
normal. Or what society calls normal—I should say. So I know she
would never go to a person to help them...
Benazir explained why psychological help is not accessed:

.. .1 think it's the people don't understand why you need to

go. They just don't understand why you need to go. What's
wrong.. .things can't be that bad you know uh umm uh.. .1 mean I
 75

have no idea where the other people are coming from except they
don't see it they don't see why its necessary. They don't see why
it's helpful.. .how it's going to help others...
Zainab discussed the fear of the unknown or lack of understanding when it comes to
seeking psychological treatment:

Yeah and I think that there is fear of oh okay I know what

happens when I go to a doctor because I have been doing it since I
was 2. But okay like you have that picture of the Freudian couch
that you are laying on and like and staring off into space while you
are talking about your problems and just maybe, I don't know yeah
I think more education and letting them know that when you go for
a mental health visit these would be the sorts of things that you
.. .no you are not going to be lying on couches you know...
Variant cultural attitudes to psychological health and treatment included denying
psychological concerns/issues, and being considered weak if one admits to psychological
problems. For instance Alina stated:

I don't think very many people actually know what entails

going to a psychologist or mental health umm therapist umm
because they just don't understand you know.. .or.. .or like what
the point is of that... you know if they are having a problem they
or they might be able to just deal with it themselves so there's no
need for them to go or they just think that their lives are perfect
and you don't need to like actually be solving any problems or
they're just keeping it in the back of their mind and they don't
even think about their problems. So a lot of people don't think that
there's a need for them to go or even if there is that they wouldn't
consider doing that because that would just make them feel more
like they need more help than other people around them or they
just don't know...
Asma referred to denial and repression of psychological concerns and the preference for

possibly addressing such concerns with trusted family members rather than seeking

professional help:

I think a lot of repression... [laughs]... there' s a lot of

denial issues, umm you know unless its something tangible like a
health issue then they just kind of treat it as okay, it's a health issue
I will go do what I have to do, to address it and that's it. I think
that if you are talking about things that are a little bit more
subjective or that are less tangible maybe job stress and stuff you
know, I don't know they may just talk about it with their partners
or their families....
 76

Domain 3: Facilitators of seeking psychological

help/treatment

Participants were asked if they would consider seeing a psychologist or other

mental health care provider, and if so, what would facilitate seeking psychological help
from a professional, and what would prevent participants or members of their
religiocultural community from seeking such help. Participants identified provider
characteristics, increasing psycho-education and awareness, and generational and family
differences as playing a role in seeking psychological help/treatment.

Participants identified several provider characteristics that would facilitate

seeking psychological help from a psychologist or mental health care provider.
Categories included: a. preferring someone from the same culture and/or religious
background, and b. someone who is an experienced and competent professional of good
character, and knows the community, culture, and religion. Participants identified a need
for greater psycho-education and awareness in their community as being a facilitator of
seeking psychological help. Categories within this core idea included: a. a need to raise
awareness/decrease stigma, b. professionals should distribute pamphlets and literature,
and advertise services in the community, c. the need for professionals to host workshops
for the community, and d. the need to educate the community about privacy and
confidentiality rules. Generational and family differences included a. being born and
raised in North America served as a facilitator of seeking psychological help, b. family
being open-minded and educated, c. younger people were more likely to seek
professional help and older generation is less likely to do so.

Provider characteristics were an important facilitator of seeking psychological

help/treatment. Participants typically preferred that the provider should be someone from
the same cultural and/or religious background, or someone that is familiar with the
community, culture, and the religion. Variantly, participants identified that the
professional's level of experience, competence, and character were important
considerations. For instance, Maryam disclosed her experience with an Indian counselor,
and her preference of seeking services from a provider of a similar cultural or religious
background:

I guess find umm someone that may be.. .is of the same
culture as you if possible, like the counselor I had she was Indian
so she understood the dynamics of culture and she knows like the
Muslim religion and everything so she could like understand every
little thing that I was going through, that maybe like a Caucasian
person wouldn't understand or a Hispanic person wouldn't
understand. So I guess trying to find someone who understands
where exactly you are coming from, so someone who has that
understanding of the culture. So maybe a Muslim person someone
raised in a Muslim country can understand what the problem is.
Saadia explained why she would only want to go to a Muslim psychologist:

Well okay I know personally for myself if I were to go to a

psychologist I'd want to go to a Muslim psychologist because
me... like I'm very I want to try I try to be very spiritual I try to be
like umm you know Islamic in every facet of my life so I would
want the.. .the like the objective guidance from the psychologist
but then I'd also want like some kind of spiritual guidance too...
For Asma the character and experience of the provider were important:

I guess there is one thing and that would be talking about

the character and the experience of the provider themselves. Umm
my concern would be finding someone who not necessarily knew
firsthand what my unique experiences as not only an American but
as a South Asian Muslim American but somebody who is at least
willing to accept that- that's a different reality from may be some
other—other context or any other mixture of that typical
background right? You know I think it would be important to find
people who are open to that and if somebody was not, if somebody
was across the board like you know this is what my "x" diagnosis
is that will apply to you regardless of where you are coming from
and what religious beliefs guide your life and what values you
have whatever and I think that only works with issues that are
rooted in a medical background...

She goes on to say:

.. .yeah a provider would have to be open to that you know

I am not asking that somebody knows exactly where I am coming
from but they have to at least be willing to accept that you know
my background is unique and that informs a lot of where I am
today physically, mentally, psychologically the whole nine yards,
and if someone ignored this I would probably not see them.
 78

Both Benazir and Neelofar emphasized the importance of the provider earning the respect
and trust of people in the community. Benazir stated, specifically referring to non-
Muslim providers:

.. .they would have to go through the same process type of

thing winning the respect of the people you know earning that
respect and the way to earn it is they gotta have the knowledge of
the culture and the religion umm they have to be sensitive and they
have to be around Pakistani Muslims too you know like make
themselves known and umm be a good role model I think...
Whereas Neelofar stated that providers have to build trust with the client:

Just present themselves in a manner that shows you know

that you can trust me I am not going to go home and tell your
mother I am not going to go discuss it with my husband my kids
are not going to know. It's between you and I.
Increasing psycho-education and awareness in the South Asian American Muslim
community was identified as a facilitator to seeking psychological services. Participants
typically stated that there is a need to increase awareness surrounding issues of
psychological health, and typical suggestions included that providers distribute
informational brochures and pamphlets, as well as advertise their services to the
community. Hosting psycho-educational workshops at mosques and/or community
centers was also typically endorsed. A variant response was that of educating South
Asian American Muslims about the confidential nature of the therapeutic relationship.
Rihanna stated:

I think.. .well you would have to educate, I mean, I think

honestly because we're all like growing up here that like
eventually the stigma will possibly not be as strong but I think that
educating them and you know saying that umm coming to a
psychologist doesn't mean that you are crazy, its you're getting
help just sorting out your feelings, so I think like just educating the
population, really important...
Maryam suggested that:

.. .workshops are a good way or maybe going to like

community functions and umm kinda like telling them just a
general overview that umm if you are ever feeling this way its
okay there's nothing you know.. .its not shameful or this or that
kinda like basically bringing awareness to these issues.
Ayesha suggested the mosque as a venue:

Umm maybe like giving umm talks and lectures just about
your services and what you do for example at the mosque they
have like meetings like where a lawyer will speak about like
immigration and laws and things so like a psychologist goes and
speaks at the mosque about what services they offer and what kind
of things they can help with and how they go about doing that
umm I think then more people would understand and be willing to
seek that help.
With regards to educating the community about privacy and confidentiality Salma stated:

I think advertising especially, you know like get the word

out there you know this is our number this is what we can do for
you umm and you know we're confidential you know and like all
that good stuff you know or if they have to pay like what would be
the fee and that sort of thing just so that their mind can be at ease
you know going in, and they don't have to stress about legal issues,
they don't have to stress about their scary husband finding out you
know...
Neelofar underscored the importance of the psychologist or mental health care provider
informing community members about confidentiality especially if the provider is South
Asian and of the particular religious community:

I am here for you whether you choose to (use me or not)

fine but I'm here. And everything will be confidential. That's
another thing that I think people think is like just because like I can
say for myself.. .if you were a psychologist and you came to the
mosque I'd be like well does she know my mom? I mean what if I
talk to her.. .like of course there's like the whole HIP AA and then
there's just the oath that you guys take that it'd be confidential but
she's still desi1 like is she going to tell my mom like what if its
bad? And there's always going to be that doubt in your mind. Like
in my mind...
Generational and family differences were also identified as playing a role in seeking

psychological treatment. Typically participants stated that being born/raised in North

America they were more open to seeking psychological treatment, and that younger
people were more likely to seek professional help than the older generation. Participants
variantly stated that the family's level of education and open-mindedness also acts as a

Desi is a term that refers to persons of South Asian heritage.

 80

facilitator of seeking psychological treatment. This is further the case when there are
family members who are in the mental health field. For instance a couple of participants
indicated having uncles or aunts who are psychiatrists.

Maryam referred to generational differences in the recognition and awareness regarding

psychological treatment:

I honestly think second generation Pakistanis if there is a

problem they would go, because their parents would be
understanding of something, and a lot of the first generation kids
don't have that in their parents.
Asma added:

...I think my generation like you know growing up mostly

as first generation American we are much more open to you know
what sometimes you do just need a little bit of help... [laughs] and
that's okay and, if you know I am so sure that when I am hanging
out with people like with other first generation Americans Muslims
my friends my cousins whatever and if we are all just accepting of
that then that just, it creates an environment of openness where its
okay so if I am seeing a therapist for example, I may not be so
willing to tell my parents about it because they will freak out and
think that there is something really wrong you know when it just
may be just be that I just want to talk to someone.

Domain 4: Common psychosociocultural concerns

Participants were asked to identify psychosociocultural concerns for their
religiocultural group. Participants identified relationship issues, parental pressures,
feeling that they are between two worlds, and indicated that concerns experienced by
their religiocultural group are a part of the universal human experience.

Relationship issues included: a. dating and opposite-sex friendships, b. domestic

violence, c. marriage difficulties/conflict, and d. choosing your own partner. Parental
pressures included: a. pressure to meet parental expectations, b. pressure to get married in
a timely manner, and to the appropriate person, c. pressure to be "the perfect daughter",
d. pressure to succeed academically, e. pressure to choose and succeed in an occupation
acceptable to the parents, and f. parents not understanding their experience. The core idea
of between two worlds included the categories of: a. fitting in North American society
 81

and feeling stuck in the middle of two cultures, b. finding their own way as a South Asian
American Muslim, and c. raising Muslim children in America. Participants also stated
that the human experience is universal and this core idea is composed of a single category
illustrating participants' perspective that we all experience similar issues and concerns
regardless of our religiocultural backgrounds.

Typical relationship issues included negotiating dating and opposite-sex

friendships, especially with regards to parents' understanding of such relationships.
Marriage difficulties and conflict was another typical concern identified by participants.
Variant concerns included domestic violence, and choosing your own marriage partner.
Yasmin stated:

Uh definitely the marriage issue. Like comes up like umm

like definitely like either in getting married in a timely fashion
either that or like liking someone of your own like either of an
outside culture and that not being okay with the parents or even
like picking someone that's .. .it not suitable so there's that
whole...
Alina stated:

.. .1 mean its kind of difficult being brought up.. .its not

impossible but it's a little hard being brought up in such a
westernized culture but umm values, are not sometimes not
expected but people don't understand.
She then continued to add:

.. .my white friend might not care about like going out to
dinner with a group of guys and girls and the fact that there's guys.
My mom, my parents would care about because they wouldn't
really like that because it's not something normal that they would
do. And so.. .so of course like instances of dating and hanging out
with boys or anything related to that.. .it's like a big thing that it
just doesn't coincide.
Neelofar also commented on dating and finding a partner:

I think that the whole like dating thing. That's very hard, I
mean.. .like my parents had an arranged marriage. Umm you know
mashaallah? they are very, very happy and you know they're

Mashallah an Arabic term that means Praise be to God.

 82

good. And they knew each other before marriage but you know.. .it
was still arranged, and I think that's like you know now its hard
to.. .1 don't want an arranged marriage but I really can't go out on
like dates or go spend the weekend with some man or just you
know things like that.. .so its kind of a challenge. On how do I
move on like how do I find somebody?
Participants addressed marriage difficulties/conflict and domestic violence by
providing narratives of incidents that have occurred to friends or family members.
Parental pressures are another common concern experienced by this population. Within
this core idea typical categories included the pressure to meet parental expectations in
general, and the pressure to succeed academically. Variant concerns included the pressure
to get married in a timely manner, and to the appropriate person, pressure to be the
perfect daughter, pressure to choose and succeed in an appropriate occupation, and the
feeling that parents just do not understand the experience of this generation.
Mary am stated:

Well, I know there's a lot of pressure to be perfect, like the

perfect daughter you know brought up right, you know uh
whatchamacallit.. .Uhhhh good in school, you know stuff like that
so I think sometimes when the pressure is so much that a person
just cracks. And they don't and they think 'oh if you're not if
you're not you know, doing what you are supposed to do then
you're being lazy or you're being bad or you're being westernized.
Zainab commented on parental pressure regarding marriage:

Oh okay, for example like when you get married... like

your religion says that as long as it's a practicing Muslim you can
marry whoever you want. But our parents say 'oh no they have to
be from Pakistan and from this province and from this area and
raised that way' and you know and they have all of these criteria
that are kind of more culturally set than religiously...
Benazir commented on the pressure to succeed academically in the appropriate discipline
as defined by the parents:

Umm I know a few people in general that are starting to go

to college so they are in college right now my nephew and stuff
you know they really want to make their parents happy and go into
either science fields or something that umm but they struggle they
are like but I really want to be a history professor you know and I
my advice to them is well be what you like to be because you
know they are not going to be around forever respect their wishes
you know do something good and make them proud as (inaudible)
 83

but you have to choose yourself what you want to be.. .you have to
go to work everyday. Cos now they are thinking you don't work
you just enjoy it...
Mehwish referred to cultural expectations:

I think social norms [laughs] within the umm within Indian

community in terms of I think a lot of the mothers want their
daughters to be a certain way. They want their sons to be a certain
way and they may not turn out the way that they want them to be
because the American culture is very vast and its growing in all
directions and their child could take one step in one direction and
they would want them to go in the other.
She continued to say:

So the social norms, and then and then within the Indian
culture umm you know even within the Muslims and you know the
Indian culture has a lot with... you know what you wear and how
you sit and how you eat and are you pretty, think.. .and I think a lot
of girls suffer you know in their teens with that in their teens if
they don't if they don't achieve those norms.. .they are worried
because their parents again want them to get married, they want
them to get those proposals and you know so its hard for the girls
growing up here and then they.. .but they don't want them to marry
outside of that so they want them to be in that circle and be married
in that circle.
The "circle" refers to an appropriate partner of South Asian Muslim background.

Participants also variantly discussed negotiating and trying to fit into two cultures, that is,

the American culture and the South Asian Muslim culture. Yasmin stated:

... I know like for people who just move here.. .like I see a
lot of people like that at my mosque and stuff.. .umm like for them
a lot of it is navigating their way through the culture here umm and
like for my parents surprisingly its still kind of sometimes is an
issue you know umm we don't really have that issue, but at the
same time we do have the issue that we're umm like over here we
are considered different you know we are not considered
Americans but when we go back to Pakistan nobody considers us
Pakistani either there.
Ayesha articulated the challenge of raising Muslim children in America:

I guess like raising children and how to go about doing that

how to have a balance between you know sheltering them like
protecting them but not alienating them so they can.. .you know
when they go out into the real world they need to be able to you
know function and get along with others...
And suggested that these concerns cross religious lines:
 84

.. .Even non-Muslim community like raising your kids and

you know like now on youtube everywhere there's like you know
girls beating up on other girls and you know and I think I mean
everyone's concerned about that its not just you know people that
are religious they want their children to have a safe place...
Overall participants typically stated that although they were identifying concerns
pertinent to their community they felt that these concerns are all part of the universal
human experience, and not specific to the South Asian American Muslim community. As
Asma stated:

I think everybody has umm challenges in all of those

aspects of your day-to-day life and at anytime any of those aspects
of your life can just can become a little bit more stressful than
normal.

Domain 5: Coping with psychosoiocultural concerns

In addition to identifying psychosociocultural concerns participants were also

asked to identify coping mechanisms in place for managing these concerns. Participants
identified the core ideas of religious methods of coping, seeking informal support, and
other coping methods. Religious methods of coping included: a. prayer, b. following

Islam, c. talking to the Imam, d. asking Allah for guidance. The core idea of seeking

informal support included: a. developing peer support networks, b. confiding to friends,

c. confiding to family. Participants also identified seeking professional help as a method
of coping. Other coping methods included: a. hash it out/work it out, and b. walk away
from the situation.
Participants identified several ways of coping with psychosociocultural concerns.
With regards to using religious methods of coping participants typically endorsed that

following Islam keeps one healthy, and variantly stated that prayer, talking to an Imam
and asking Allah for guidance are helpful religious coping mechanisms.
Lay la stated:

I think prayer is the only thing that has gotten me through

like everything.
Rihanna added:
 85

I think it's a huge thing, I think that if you have religion—

because I personally think that Islam is like, if you have any
questions or anything I think that has all of the answers so I think if
you have that in your life, religion like it solves all problems.
Seeking informal support, typically via confiding to friends and family was an important
coping mechanism. Participants variantly stated that developing and relying on peer
support networks was helpful, specifically with regards to parenting.
With reference to developing peer support networks Ayesha stated:

Umm I think talking with other people that are in the same
situation that helps a lot. And seeing what.. .what methods they use
and compare it to your own or.. .or adopt their methods or you
know just being with other people.. .cos once you talk to other
people you realize oh I am not the only one or you know
everyone's going through the same thing.. .so umm support groups
and just people talking to each other.
Zainab commented:

I think we're much better in our generation in developing

support networks and going to people for help and umm I think
that we are better at expressing the issues psychologically -[baby
crying in the background, participant inaudible].. .1 think it's just a
matter of talking about the issue that will help make you feel better
about it.
Salma discussed relying on the support of her friends as well as providing support to her
friends:

Yeah. So like whatever even if it's like 3 am in the

morning, my friend's like oh all depressed she'll be like
[participant begins to talk in a whiny voice] 'Salma' and I'm like
Oh God! She woke me up for this.. .and my friend.. .that's what
helps her out, so I am happy to be there for her.
Participants also typically endorsed seeking out professional support as a means to cope.
Benazir stated that she would seek out professional help if needed:

I would... [laughs] I would. If the help is out there.. .then

get it! I mean even if you get nothing out of it, every experience is
a learning experience and you learn from it.
She added a caveat:

I probably wouldn't tell any [inaudible]...people because

like they.. .they won't understand.
 86

Participants valiantly stated that they would, depending on the situation/concern either
hash out the problem/issue with the relevant person, or walk away from it if it is too
much to handle at the moment. For instance Salma stated:

Umm okay there are a couple of ways of going about that

one you can run away from it completely, which I don't think
that's a solution. Umm, I personally think that you should if there
is a problem you should hash it out you know you need to go
through it even if its hard. That's like you have to go through it
you know...
Alina added:

Umm.. .well depending like on if I am having [inaudible]

this discussion with my parents the only thing that would make me
feel better or like a fight or whatever you need to resolve it with
the person you are having it with. So, if I'm having a disagreement
with my mom I'm going to have to talk to my mom about it. Yeah,
it will help to talk to my friends about it too and I do tend to do
that. But in the end the only thing that will make me feel better is
talking to my mom about it. And trying to get to a level where we
can understand each other and I think that's really important...
With regards to parental pressures Neelofar stated:

.. .1 really just step away I walk away from the situations I

don't want to yell at my parents I don't want to scream and be
disrespectful and but I don't want them to think that they are right
and umm just rule my life.
She continued to state:

So that's frustrating so when I deal with these kind of

pressures I stop and like you know what I can't deal with this I'm
going to walk away we'll discuss some other time. Cos I don't
want to get into a fight I don't want to ruin my relationship with
my parents over something so trivial.

Summary
Results of the study were presented in this section. These included participants'
definitions of psychological health and wellbeing, and their attitudes towards
psychological treatments. Common psychosociocultural concerns pertinent to the
participants' religiocultural community were identified, along with coping mechanisms
for these concerns. Participants also discussed facilitators to seeking psychological and
 87

other mental health care services. These results are further explicated upon in the next
chapter, and are discussed with reference to research literature reviewed in Chapter 2.
 88

CHAPTER 5

RESULTS

The current qualitative investigation explored the definitions of

psychological health and wellbeing, and attitudes towards help-seeking among a
relatively understudied population, that is, South Asian American Muslim
women. Unlike previous empirical studies that have explored this area the current
study specifically focused on first generation South Asian American women, that
is, those who had been born or raised in the United States for most (that is, at least
three quarters) or all of their lives. Additionally the current study incorporated
both culture and religion into the research questions and interview protocol, rather
than using religion as a demographic descriptor only, as has been the case in
previous studies. Measures assessing religiosity and identification with cultural
beliefs and values were also utilized. These measures served to further describe
the participants' level of religiosity and acculturation rather than relying solely on
self-report.

Specifically, this study used semi-structured interviews to ascertain South

Asian American Muslim women's definitions of psychological health and
wellbeing, identification of psychosociocultural concerns experienced, attitudes
towards help-seeking and identification of resources accessed in order to alleviate
psychological distress. Furthermore the current study was not only an attempt to
gain a better understanding of this population's definitions of psychological health
and attitudes towards help-seeking, but also to understand how psychologists and
mental health professionals can better serve this population.

This chapter further explicates the results that were presented in Chapter 4.
These results are discussed in terms of the five domains (definitions of and
 89

attitudes towards psychological health and treatment, culture, facilitators of

seeking psychological help/treatment, common psychosociocultural concerns, and
coping with psychosociocultural concerns). Next, the limitations of the study will
be discussed, followed by some implications for practice and suggestions for
future research. Finally, a summary and conclusion to the study will be provided.

Domain 1: Definitions of and Attitudes towards

Psychological Health and Treatment

In this domain participants provided their personal and religious

definitions of psychological health, as well as personal and religious attitudes

towards seeking psychological treatment. In contradiction with the research

team's expectation participants were open to seeking out services from

psychologists and mental health professionals, and maintained a positive view of

these professionals. However, the current sample indicated that seeking out

professional help should only occur when one is severely distressed. This finding

aligns with reports from previous literature (Bradshaw, 1994; and Das & Kemp,

1997) which suggests that South Asians tend to seek professional help only when

other resources have been exhausted, or if it is a severe concern for instance,

bipolar or schizophrenia that is recognized as warranting medical or psychiatric

attention.

Despite the reluctance to seek professional help six participants had sought
treatment from a psychologist or a mental health care professional. Only one of
the six participants worked with a South Asian American professional. The fact
that most of the participants expressed positive attitudes towards seeking out
mental health professionals and almost half of the sample has utilized mental
health services appears to be at odds with the literature reviewed in Chapter 2,
where it is suggested that South Asians are more likely to rely on traditional
methods for instance herbal remedies, and traditional healers to address mental
health concerns (Hilton et al., 2001) than to access professional help.
The current sample included participants who are either first generation
South Asian American, or have been raised in North America (that is, lived here
for at least three-quarters or all of their lives). Existing empirical literature on
South Asians in North America has tended to focus on the immigrant experience
(for instance, Bradshaw, 1994; Das & Kemp, 1997; Hilton et al, 2001; and
NAWHO, 1996), or if first generation South Asian Americans are included in the
sample there are not sufficient participants to distinguish if this group is different
from the immigrant group in terms of their perspective (e.g., Khan, 2006), even
though the researcher may attempt to tease this out (Haque-Khan, 1997). This
specific finding, that is, openness to accessing psychological services could be
accounted for participants' being raised and educated in North America.

The participants in this sample appear to be aware of and educated about

psychological health concerns and avenues for seeking professional help.
Additionally, the participants were fairly acculturated into American society, and
were from communities where they had sufficient interaction with members of
other minority and majority groups as opposed to primarily South Asian
entrenched neighborhoods (for example, Jackson Heights in NYC, Devon Street
in Chicago).
The research team expected that participants would identify the mind-
body connection when defining psychological health, in keeping with the
tendency of South Asians and Muslims to view health holistically (Hilton et al.,
2001). However, only two participants referred to the importance of keeping both
the mind and body healthy and did so in the context of religious teachings and
 91

beliefs. The religious definitions and attitudes towards psychological health and
treatment consistent with those cited in previous literature (Ahmed & Lemkau,
2000; Ali, 2006; Amini, 1997; and Mahmood, 2005), that is, the importance of
following religion and seeking closeness with and reliance upon Allah, and that
religious teachings encourage one to take care of psychological as well as
physical health concerns.

Domain 2: Culture

Participants provided cultural definitions of psychological health, and

cultural attitudes towards seeking treatment. The collectivistic cultural value of

the importance of family is apparent in this domain. South Asian culture places a

primary emphasis on family, and this is indicated in participants' definition that

one's psychological health is dependent on the wellbeing of one's family as well

as whether one is meeting familial expectations or not. Additionally participants

refer to the restraint of emotions in maintaining one's psychological health by

referring to the idea that one has to put on a happy face and/or act normal in order

to maintain equilibrium. Both the importance given to family concerns and

restraint or hiding of one's real emotional state are characteristic of South Asian

culture (Ahmed & Lemkau, 2000; Dasgupta, 2002; Inman, 2006; and Naidoo,

2003), and also of other collectivistic and/or regional cultures, for example,

Midwestern culture.

Several participants referred to psychological health being dependent upon

one's financial stability, specifically stating that was something their immigrant

parents emphasized as being the definition of psychologically healthy. This

indicates that social class status and psychological health are perceived to be
 92

interdependent. Three participants specifically addressed the lack of emphasis

placed on psychological/mental health concerns in the culture. This is consistent

with the cultural attitudes of keeping problems or concerns of any kind hidden or

within the family, for fear of bringing shame to the family, or losing the

reputation of one's family in the community, as well as taboo and stigma

associated with psychological health concerns specifically (Ahmed & Lemkau,

2000; Das & Kemp, 1997; and NAWHO, 1996). For instance, South Asian

culture generally assumes that psychological health concerns run in the family

(Jayakar, 1994), hence one does not discuss family members who might be

experiencing a psychological illness, as one participant expressed this could have

implications for marriage, especially, with regards to marriage proposals, and

one's eligibility as a spouse. Since both South Asian culture and Islam emphasize

marriage, this is a valid concern for these women. Additionally, as is the case with

other minority populations South Asian American Muslims lack an awareness and

understanding of psychological services, and hence may not understand why the

need for such services exists (Kobeisy, 2004).

Domain 3: Facilitators of Seeking Psychological

Help/Treatment

As a component of inquiring about help-seeking behaviors, participants

were queried about what would facilitate seeking psychological help/treatment for

them. Consistent with previous research (Chew-Graham et al, 2002; Haque-Khan,

1997; and Kelly, Aridi, & Bakhtiar, 1996). Participants indicated their preference

for a professional from a similar cultural or religious background, but also stated
 93

that they would consider working with a professional who was knowledgeable

about their culture and religion.

One of the studies reviewed in Chapter 2 (NAWHO, 1996) indicated that

South Asian women would be reluctant to seek help from a South Asian

professional due to fear of being discovered by the community. This concern was

briefly mentioned by one participant but was not expressed by the majority of the

women interviewed. However, the participants did state the need to educate South

Asian American Muslims about privacy and confidentiality issues with regards to

psychological services (also mentioned by Kobeisy, 2004). Previous research

implied that insufficient knowledge regarding confidentiality, combined with the

fear of being discovered as a consumer of psychological services by community

members prevents South Asians from accessing psychological services (Chew-

Graham et al., 2002). South Asian American Muslims are also more likely to stay

in treatment if they know what to expect from it (Kobeisy, 2004; and NAWHO,

1996), hence it is important to work towards raising awareness and education

regarding psychological services, and to collaborate with religious and cultural

centers by serving as liaisons, getting to know the community, and/or hosting

workshops and presentations pertaining to common health concerns, for instance,

hosting an innocuous workshop/seminar on stress management.

As mentioned in Kobeisy (2004) the participants of the current study

pointed out that being born and/or raised here, as well as coming from educated

backgrounds contributed to their open outlook towards seeking psychological

help. There has been a tendency in the research literature to emphasize that South
 94

Asians seek help via traditional sources including herbal remedies, and turning to

traditional healers, however these sources were not mentioned by the women

interviewed. This suggests that South Asian American Muslim women are able to,

and do identify and understand what professional psychological treatment may

entail and are open to accessing these services, with the caveat that the

professional be a culturally sensitive provider. Additionally, it should be noted

that the current sample is composed of participants of middle to upper social class

standing, and all participants are either currently receiving or have already earned

a college degree.

Domain 4: Common Psychosociocultural Concerns

In order to understand the methods of help-seeking and coping utilized to

manage psychological concerns/issues, the participants were asked to comment on

psychosoiocultural concerns that they had experienced themselves or had seen in

their community. The women participating in the study were between the ages of

20-35 and a little over half of the participants were still single, and either getting

ready to finish college, in graduate school, or beginning their professional career.

Hence relationship issues were important for these women. Specifically

navigating dating and opposite-sex friendships in order to find a marriage partner

on their own. There are cultural and religious restrictions with regards to dating

and opposite-sex interactions, and culturally these restrictions are applied more

stringently to women (Mahmood, 2005). Participants vaguely identified marital

difficulties and conflict as an issue, but stated this more in terms of seeing a need
 95

for pre-marital, and marital counseling to be offered in their cultural and religious

centers.

For this generation pressure from immigrant parents is an important

psychosociocultural concern and has an impact on participants' and their peers'

psychological health. Participants reported experiencing stress from the pressure

of parental expectations, which varied from the typical expectations of South

Asian immigrant parents of academic success, in an approved discipline leading

to an acceptable occupation (for example, medical doctor, lawyer, or engineer).

For the women in the study more specifically there was pressure to be the "perfect

daughter" which included being able to be American outside of the home, and

South Asian within the home and cultural community (Dasgupta, 2002; and

Handa, 2003). Additionally there is the added pressure of marriage. In South

Asian culture pressure for women to get married usually begins when they are in

their teens with the expectation that they will get married by their early twenties.

Parents expect their daughters to marry a partner who is South Asian Muslim and

from the same ethnic group (e.g. Punjabi, Gujarati, Sindhi) as well as similar

social class standing. This can be an issue, as there might not be any South Asian

Muslim males that meet these requirements in the community. The women do

mention and are aware that according to Islam they are encouraged to marry

someone who is a good Muslim regardless of cultural or ethnic background. The

pressure of marriage and choosing a 'suitable' partner is one where religion and

culture are at odds, and it is also an issue that results in psychological distress for

South Asian American Muslim women.

 Another issue that has been addressed in the literature on South Asians in

the American diaspora is that of balancing both the South Asian and American

identities (Dasgupta, 2002; and Handa, 2003). The participants refer to this

concern with regards to raising their children as Muslims in America and the

challenge of inculcating religious beliefs and values into their children, while also

developing their South Asian American identities. The participants were aware of

contradictions between culture and religion and tended to emphasize religious

identity rather than cultural identity for themselves and their children.

An interesting finding in this domain was the emphasis participants placed

upon clarifying that the psychosociocultural concerns they identified were not

necessarily unique to their cultural and religious groups, but were concerns that

are commonly experienced by other cultural and religious groups in the United

States. Emphasizing commonalities could be a way of communicating that as

South Asian Americans and more specifically as American Muslims they are not

that different from other American minority or majority groups. Additionally,

since September 11, 2001 American Muslims, as well as South Asian Americans

have been under additional scrutiny, and have been identified as 'other' and

foreign. Media reports focus on portraying a xenophobic picture of this population

and thus it makes sense that the participants interviewed would like to emphasize

that they are not as different as the media portrayal makes them out to be. This is

also important for psychologists and other mental health care providers to

understand, especially when it comes to South Asian American Muslim women,

as there is still the tendency to ask questions such as "where are you from" and
expecting the answer to be that of the client's parents' country of origin whereas

the client may identify with her American heritage. Hence, providers should

acknowledge their client's American heritage but also be mindful of the

ethnic/cultural and religious identification of their client and how this may or may

not be impacting the presenting concern.

Domain 5: Coping with Psychosociocultural Concerns

In addition to identifying seeking professional help as a means of coping

with psychosociocultural concerns, participants also identified religious methods

of coping, as well as more informal means of support such as developing support

networks, for instance connecting with other parents to discuss parenting issues,

and confiding to friends and family members. These results are consistent with

previous literature. South Asian cultural values, as well as Muslim values of

collectivism result in seeking support from family members and close friends as

indicated in previous research (Das & Kemp, 1997). Religion is also an important

means of coping and consistent with previous literature (Kobeisy, 2004)

participants indicated that following Islam, prayer, turning to Allah, and in some

cases seeking out the Imam for help are all means to deal with psychological

distress.

Participants typically endorsed seeking professional help for psychological

concerns. This result could be a function of participants' awareness regarding

psychological services and can also be partially accounted for by gender. That is,

previous research literature indicates that women are more open to seeking

professional help, and exhibit positive attitudes towards help-seeking than men
 98

(Bradshaw, 1994). This is also true for Asian American women (Atkinson &

Gim, 1989) and for Muslim women (Khan, 2006).

Limitations

The current study adds to the scarce literature on South Asian Americans

as well as American Muslims, and also sought to address the impact of both

culture and religion upon the definitions of and attitudes towards psychological

health and help-seeking. However, there are several limitations that must be

addressed.

Firstly, although the CQR recommendations were followed when

determining the sample size, by virtue of being a qualitative approach the sample

size for the current study was fairly small. Second, due to the relatively small

sample size the generalizability of the results is limited. Thirdly, the homogenous

sample of participants, although in accordance with CQR methodology limits the

diversity of the sample. For example, the recruitment method that worked

primarily was email listservs and personal networking. This limited the diversity

of the sample specifically in terms of social class, that is, many of the participants

were recruited via listservs affiliated with a university student organization, and

thus were well-educated or in the process of receiving higher education degrees.

The participants were also from well-off families, and identified themselves as

being of a fairly high level of social class standing. The composition of the

sample thus perpetuates the myth of South Asians being a "model minority" (Das

& Kemp, 1997). Additionally the homogeneity in terms of social class standing,

and education may have impacted the results obtained. Fourth, the participants
were recruited from two communities in the United States (Tampa, Florida, and

the Albany area in New York), hence geographical factors, in addition to

educational level, social class, and age have likely influenced the responses of the

participants, and thus will impact the generalizability of the results, additionally

the results may not be representative of the experiences of South Asian American

Muslim women of varying social class and educational backgrounds across the

United States. As previously stated the geographical limitations on recruitment

were due to the primary investigator's location of residence and relationship with

the specific communities from which participants were recruited. Fifth, there is

limited data on the applicability of the acculturation and religious measures used

in the demographic questionnaire for this population. However, these measures

were used primarily as descriptive tools in order to illustrate the participants'

identification with Asian cultural values, as well as religious identification rather

than relying solely on self-report.

The semi-structured interview in and of itself can be a limitation, as the

type of information garnered is dependent upon the questions posed, and thus

other important information, and/or perspectives participants wished to have

shared may have been lost. Finally, it was difficult to recruit participants for the

study as any research whether conducted by an in-group or an out-group member

is viewed suspiciously in today's climate by the American Muslim population.

Hence, the women who did agree to participate may have biased the results, due

not only to their demographics, but also by feeling the responsibility to positively

represent their cultural and religious group. Future studies should focus on
drawing participants from varying educational, social class, and geographical

backgrounds in order to obtain a better understanding of South Asian American

Muslim women's views of psychological health and attitudes towards help-

seeking.

Implications for Practice and Research

Despite the limitations mentioned above the current study provides some

important implications for practice and research.

Practice Implications

It is important for psychologists and mental health professionals to

recognize that these women identify both with their American and South Asian

heritage. Providers should educate themselves on South Asian American Muslim

cultural and religious beliefs and values that may be important to consider during

treatment. The participants interviewed mentioned the need for raising awareness

about psychological health concerns, as well as defining psychological treatment

in their communities. Thus, practitioners should collaborate with and reach out to

local South Asian cultural centers, as well as mosques in order to build

relationships with leaders in the community and to develop a better understanding

of the needs of the community. Practitioners should also attend community

events, and as suggested by the participants interviewed distribute psycho-

educational materials, business cards/contact information, and host

seminars/workshops in cultural centers and mosques. The process of

psychotherapy for South Asian American Muslim clients needs to be clarified in

order to remove misconceptions or misinformation that exists about

psychotherapy. When working with this population practitioners should recognize

that both cultural and religious factors impact the client and should take steps to

ensure that treatment options utilized do not contradict their clients' cultural and

religious values.

Participants had also expressed a preference of seeking services from a

culturally and/or religiously similar psychologist or other mental health care

provider. Thus, a recommendation would be for clinical training programs to

recruit students that are members of South Asian and Muslim populations, as this

will serve as a facilitator to seeking psychological services for this population.

Research Implications

This study was an initial attempt at exploring South Asian American Muslim

women's perspectives of psychological health and attitudes towards help-seeking.

Although, the qualitative methodology of the study made it possible to accrue rich data,

the sample size was fairly small, and thus likely not generalizable to the South Asian

American Muslim population across the United States. Although Hill et al (2005)

recommended that samples be as homogenous as possible, it would be interesting to see

if there was any variance in definitions of psychological health and attitudes towards

help-seeking across social class standing. It would also be interesting to replicate the

current study with South Asian American Muslim males to explore any gender

differences, as well as to identify gender-specific concerns. Similar qualitative

investigations among different South Asian American Muslims communities in the

United States are warranted to obtain a more general picture of South Asian American

Muslims' views on psychological health and attitudes towards help-seeking.

 102

The current qualitative study could also be used as a beginning point for

designing a quantitative investigation, as well as potentially developing a quantitative

measure assessing attitudes towards help-seeking, and resources relied upon for coping

with psychological distress among the South Asian American Muslim population. It

would also be interesting to conduct empirical research with other ethnic American

Muslim groups (for instance Hispanics, Arabs, African American, White) to tease out the

role played by religion and culture in defining psychological concerns, and attitudes

towards help-seeking. Future studies may also compare the American Muslim population

with other collectivistic communities in the United States (for instance, other ethnic

minority groups, and/or rural communities) to seek out similarities and differences in the

definitions of psychological health and attitudes towards help-seeking.

Summary and Conclusion

This study sought to understand South Asian American Muslim women's

definitions of psychological health and wellbeing, identification of psychsociocultural

concerns experienced by this population, and the attitudes towards help-seeking and types

of resources accessed in order to alleviate psychological distress. The investigation was

conducted qualitatively using CQR and utilized semi-structured interviews. Overall,

participants defined psychological health and wellbeing in terms of being happy and

positive, and being able to adequately manage stressful situations and obstacles as they

arise. The psychosociocultural concerns expressed by participants were underscored as

concerns that anyone may experience by virtue of living in the United States. However it

is important to note that cultural and religious beliefs and values need to be considered

when treating South Asian American Muslim women. The women interviewed for the
 103

study were aware of, and open to accessing services from psychologists and other mental

health care professionals with the caveat that the professional be familiar with their

cultural and religious beliefs and values.

Overall, the definitions of psychological health and attitudes towards help-seeking

appear to be similar to those that are expressed by other ethnic groups in the United

States. Cultural and religious definitions and attitudes may be somewhat specific to this

group, however, individuals from collectivistic cultures, for instance, other ethnic

minority groups (such as, Hispanic), religious groups (e.g. Jewish) or those living in rural

communities, may also express views similar to those expressed by this particular

population. Although further research is warranted on this area for the South Asian

American Muslim population, it would appear according to the views expressed by the

participants that the many ethnic and religious groups in the United States are likely to

have more in common with each other by virtue of sharing in the human experience.
Table 1. Participant Demographics

Years lived in Religious

Name Age Ethnicity N. America Identification Occupation
Layla 24 Pakistani American 23 Muslim Student
Mary am 21 Pakistani American 19.5 Shia Muslim Student
Indian/Pakistani Canadian
Rihanna 23 American 23 Sunni Muslim Student
Salma 20 Bengali American 16 Muslim Student
Saadia 20 Pakistani American 20 Muslim Student
Yasmin 22 Pakistani American 22 Shia Muslim Student
Asma 31 Pakistani American 31 Sunni Muslim Non-profit political development NGO
Zainab 26 Pakistani 26 Muslim Program Coordinator
Benazir 31 Pakistani 23 Muslim Housewife and student
Alina 23 Bangladeshi American 18 Sunni Muslim Med Student
Mehwish 29 Indian American 29 Sunni Muslim Homemaker and Homeschool mom
Neelofar 27 Pakistani/Indian American 27 Sunni Muslim Medical Secretary
Ayesha 34 Pakistani American 34 Muslim Stay at home mom
Table 1. Continued

Marital Number in
Name Education Status Household Children Income Social class ladder
Layla B.S. Single 5 0 Refused/DK 4
In a
Mary am Senior relationship 5 0 50-59,999 5
Rihanna 1st year grad school Single 4 0 Refused/DK 7
Salma Senior Single 5 0 60-69,999 5
Saadia Junior Single 7 0 100,000+ 4

B.S. Medical Sciences, In a

Yasmin 1st year med school relationship 5 0 100,000+ 7
Asma M.A. Single 1 0 40-49,999 6
Zainab Master's degree Married 4 2 70-79,999 6
Benazir B.A. Married 4 2 100,000+ 9
Alina in Med School Single 1 0 0—none is student 9
Mehwish Bpharm Married 5 3 70-79,999 7
Neelofar B.A. Single 4 0 90-99,999 5
Ayesha B.S. Married 6 3 100,000+ 8
Mean: 6.3
Standard deviation: 1.7
Table 2. Summary of Participant Responses to Measures

Name AVS-R RCI-10 MARS

Layla 68 45 68
Mary am 62 34 61
Rihanna 58 28 60
Salma 65 36 64
Saadia 53 50 69
Yasmin 61 43 60
Asma 39 37 66
Zainab 61 41 61
Benazir 67 49 69
Alina 66 25 51
Mehwish 67 46 68
Neelofar 57 29 61
Ayesha 63 45 68

Overall Average 60.538 39.0769 63.538

Standard Deviation 7.84 8.25 5.22

Note: AVS-R: Asian Values scale-Revised—Based on a likert scale, responses vary from 1-4, higher numerical responses indicate
greater endorsement of Asian values. Maximum score: 100
RCI-10: Religious Commitment inventory—likert scale (1-5), higher scores indicate greater religiosity. Maximum score: 50
MARS: Moslem Attitudes towards Religiosity Scale, specific to Islam, and adherence to Islamic practices. Likert scale (1-5).
Maximum score: 70
Table 3.
Domains, Categories and Frequency of Participants' Responses

Domain Core Idea Category Frequency

Definitions of and attitudes Personal definitions and
towards psychological attitudes
health and treatment
Psychologists are helpful, important, and necessary. Typical
Being psychologically healthy is to be balanced and stable. Typical
Being psychologically healthy is to handle obstacles/solve Variant
problems.
Being psychologically healthy is to be happy, positive, Typical
content and at peace.
Should seek professional help when things are Variant
bad/severely distressed
I have been to a psychologist/counselor. Variant
Religious definitions and
attitudes
Wellbeing of both mind and body. Variant
Being at One with Allah and seeking out Allah helps Variant
maintain psychological health and wellbeing.
Religion encourages you to take care of your mental Variant
health.
Culture Cultural definitions of
psychological health and
wellbeing
Your psychological health depends on your family's Variant
wellbeing and expectations.
Putting on a happy face/Acting normal. Variant
Table 3. Continued

Being financially secure/stable. Variant

Culture does not clearly address mental health. Variant

Cultural attitudes towards
psychological health and
treatment.
Keep it hidden and deal with it on your own. Typical
Admitting to psychological problems is seen as being weak. Variant
It's a taboo/stigma Typical
There is a denial of psychological concerns/issues and Typical
people don't understand the need for a psychologist or why
you need to go to one.
Shame and reputation within the community or judgment Typical
from the community.
Facilitators of seeking Provider Characteristics
psychological help/treatment
Prefer someone from the same culture and/or religious Typical
background.
Experienced and competent professional of good character Typical
who knows the community, culture, and religion.
Increasing psycho-
education and awareness.
There is a need to raise awareness/decrease stigma Typical
Distribute pamphlets and literature, and advertise services in Typical
the community.
Host workshops in mosques and cultural centers. Typical
Educate about privacy and confidentiality. Variant
Table 3. Continued

Generational and family

differences
Being born/raised here more open to it. Typical
Family being open-minded and educated. Variant
Younger people more likely to seek professional help, and Typical
older generation is less likely to do so.
Common Relationship Issues
Psychosociocultural
problems
Dating and opposite-sex friendships. Typical
Domestic Violence Variant
Marriage difficulties/conflict Typical
Choosing your own partner Variant
Pressure from Parents
Pressure to meet parental expectations Typical
Pressure to get married in a timely manner, and to the Variant
appropriate person
Pressure to be the perfect daughter. Variant
Pressure to succeed academically Typical
Choose and succeed in an occupation acceptable to parents. Variant
Parents j ust don't understand. Variant
Balancing between two
worlds
Trying to fit in and feeling stuck in the middle. Variant
Finding your own way Variant
Raising Muslim children in America Variant
Table 3. Continued

The human experience is

universal.
Everyone experiences similar issues and challenges. Typical
Coping with Using religious methods of
psychosociocultural coping
concerns
Prayer gives you peace of mind, is meditative. Variant
Following Islam keeps you healthy and provides Typical
community.
Talking to Imam. Variant
Asking Allah for guidance Variant
Seeking informal support
Developing peer support networks. Variant
Confiding to friends. Typical
Confiding to family Typical
Professional Support
Seek professional help Typical
Other coping methods
Hash it out/work through it. Variant
Walk away. Variant
Note: For this sample n= 13. General^ 12 or all cases represented; typical= 7-11 cases represented; variant = 2-6 cases represented.

o
 Table 4. Participants' Endorsement of Categories

DOMAIN 1
Definitions of and attitudes towards psychological health and treatment

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
a.
Personal
Definition
sand
attitudes

Psycholog V V V V V ^ / V V V V V
ists are
helpful,
important,
and
necessary.
Being V V V V V V V V
psycholog
ically
healthy is
to be
balanced
and stable.
 Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
Being V V V V V V V V V V
psycholog
ically
healthy is
to be
happy,
positive,
content
and at
peace.
Should V V ' V
seek
profession
al help
when
things are
bad/severe
iy
distressed

K)
 Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
I have 1 1 1 _
1 1
been to a
psycholo
gist/coun
selor
b.
Religious
definition
s and
attitudes.
Well- V V
being of
both
mind and
body.
Being at V V V V V V
One with
Allah,
and
seeking
out Allah
helps
maintain
psycholo
gical
health
and well-
being.
 Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
Religion V V V V
encourag
es you to
take care
ofyour
mental
health.

j ^
Table 4. Continued
DOMAIN 2
CULTURE

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
a.
Cultural
definitions of
psychological
health and
well-being
Your V V V V
psychological
health
depends on
your family's
well-being
and
expectations.
Putting on a V V V V V V
happy
face/Acting
normal.
Being V V V V
financially
secure/stable.
Culture does V V V
not clearly
address
mental
health.
Ul
Table 4. Continued

Layla Maryam Rihanna Salma

b.
Cultural
attitudes
towards
psychological
health and
treatment.
Keep it hidden V V V V
and deal with it
on your own.
Admitting to V
psychological
problems is
seen as being
weak.
It's a V V V
taboo/stigma
There is a \
denial of
psychological
concerns/issues
and people
don't
understand the
need for a
psychologist or
why you need
to go to one.
Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
Shame and \ 1 1 1 ^ ^ ^ ^ ^
reputation
within the
community or
judgment from
the
community.
Table 4. Continued
DOMAIN 3
FACILITATORS OF SEEKING PSYCHOLOGICAL HELP/TREATMENT

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
a.
Provi-
der
Charact
eristics
Prefer V V V V V V V V
some -
one
from
the
same
culture
and/or
religi-
ous
back-
ground; __________________^___^

oo
Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmi Asma Zaina Benazi Alin Mehwish Neelofa Ayesha
n b r a r
Experi- \ > / 1 ^ ^ ^ -\7
enced
and
compet
ent
profess
ional
who
knows
the
commu
nity,
culture,
and
religio
n.
b.
Increas
ing
psycho

educati
on and
awaren
ess.

*o
Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmi Asma Zaina Benazi Alin Mehwish Neelofa Ayesha
n b r a r
There \ \ \ \ \ \ \ \ ^ >/ A/
is a
need to
raise
awaren
ess/dec
rease
stigma.
Distrib V V V V V V V V
ute
pamphl
etsand
literatu
re, and
adverti
se
service
s in the
commu
nity. _____________________

to
o
 Table 4. Continued

Layl Maryam Rihann Salma Saadia Yasmin Asma Zaina Benazir Alina Mehwish Neelofa Ayesh
a a b r a
Host 1 1 1 1 1 ^ ^ ^
workshop
s in
mosques
and
cultural
centers
Educate V V V V V
about
privacy
and
confident
iality.
c.
Generatio
nal and
Family
Differenc
es
Being V V V V V V V
born/rais
ed here
more
open to
it.

to
 Table 4. Continued

Layl Maryam Rihann Salma Saadia Yasmin Asma Zaina Benazir Alina Mehwish Neelofa Ayesh
a a b r a
Family \ 1 ^
being
open-
minded
and
educated.
Younger V V V V V V V V V
people
more
likely to
seek
professio
nal help,
and older
generatio
n is less
likely to
do so.

to
 Table 4. Continued
DOMAIN 4
COMMON PSYCHOSOCIOCULTURAL PROBLEMS
Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
a.
Relations
hip Issues
Dating V V V V V V V
and
Opposite-
sex
friendshi
ps
Domestic V
Violence
Marriage V V V V V V
difficultie
s/conflict
Choosing V
your own
partner.
b.
Pressure
from
Parents
 Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zaina Benazir Alina Mehwish Neelofa Ayesha
r _ _ _ _ _ _ ^ b r
Pressure \ -\/ -\7 1 ^ AT ->?
to meet
parental
expectati
ons.
Pressure V V V V V
to get
married
in a
timely
manner,
and to
the
appropria
te person
Pressure V V V
to be the
perfect
daughter.
Pressure V V V V V V V V
to
succeed
academic
ally
 Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zaina Benazir Alina Mehwish Neelofa Ayesha
b r
^ ^ ^
Choose
and
succeed
in an
occupati
on
acceptabl
e to
parents.
Parents V V V V V
just don't
understa
nd
c.
Balancin
g
between
two
worlds
Trying to V V V V
fit in and
feeling
stuck in
the
middle.

to
 Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zaina Benazir Alin Mehwish Neelofa Ayesha
b a r
Finding V
your own
way
Raising V V V V V
Muslim
children
in
America.
d.The
human
experien
ceis
universal

Everyone v V V V V V V
experien
ces
similar
issues
and
challenge
s.

ON
Table 4. Continued
DOMAIN 5
COPING WITH PSYCHOSOCIOCULTURAL CONCERNS

^ Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
a. Using
religious
methods of
coping
Prayer V V
gives you
peace of
mind, is
meditative.
Following V V V V V V V V V
Islam keeps
you healthy
and
provides
community.
Talking to
Imam.
Asking \
Allah for
guidance.
b. Seeking
informal
support.
Table 4. Continued

Layla Maryam Rihanna Salma Saadia Yasmin Asma Zainab Benazir Alina Mehwish Neelofar Ayesha
Developing
peer
T T T
support
networks.
Confiding V V V V V V
to friends.
Confiding V V V V
to family.
c.
Professional
Support
Seek V V V V V V V V
professional
help.
d. Other
coping
methods.
Hash it V V V
out/Work
through it.
Walk away. V V

to
00
 129

APPENDIX A
ADVERTISEMENT FOR STUDY
 130

PARTICIPANTS INVITED FOR A RESEARCH STUDY

We are inviting participants for a study that aims to learn about psychological
health concerns faced by South Asian American Muslim women, and how these concerns
are addressed. This study is being conducted by a doctoral student (Amina Mahmood) at
the University of Iowa's Counseling Psychology program. This study will involve
completing questionnaires and participation in an interview and lasts 60 to 90 minutes.

You may be eligible for the study, if you are a woman residing in the United
States and are:
1. Between the ages of 20-3 5.
2. Have lived in North America for most of your life.
3. Identify yourself as South Asian American Muslim.

All of the information you provide will be kept completely confidential. In the
event that this study is reported or published, your identity will not be disclosed. Results
will be reported in a summarized manner so that you cannot be identified.

If you are interested in participating, or have further questions please contact:

Amina Mahmood at 813-531-6863 or [email protected]
 131

APPENDIX B

PARTICIPANT SCREENING SCRIPT

 132

Script for Screening Participants

Explanation of the Study:

Hello, I am [name and title of primary research team member], a student at the

Counseling Psychology program at the University of Iowa. My research team and I are

conducting a research study examining the attitudes and definitions of psychological

help-seeking among South Asian American Muslim women.

We are conducting this study to learn about 1) psychological health concerns

faced by South Asian American Muslim women, 2) definitions of and attitudes towards
seeking help for these concerns, 3) and the impact of religious and cultural beliefs on how
psychological health concerns are defined and where help is sought to address these
concerns.

If you choose to participate in this study you will be asked to complete a

demographic questionnaire, and will be interviewed by one of our researchers asking
questions pertaining to the purpose of the study I just mentioned. The study will take
approximately one to one and a half hours of your time. Your participation will be
confidential, and the interview will be audio taped for later transcriptions.

Screening Questions:

1. Are you interested in participating in this study?

2. Do you identify yourself as a South Asian American?
3. Do you identify as Muslim?
4. Do you have a problem being audio taped during the interview?
 133

If Participant Does Not Meet Criteria:

I'm sorry you do not meet the criteria for participation in the study. Thank you

very much for you interest and time, it is greatly appreciated.

If Participant Meets Criteria:

Okay, great. You are eligible to participate in this study. We can set up a time for
the interview, right now, or if you need time to think about participating, please call
Amina at 813-531-6863 or via email: Amina-mahmoodffiuiowa.edu once you have
reached a decision. Thank you!
 134

APPENDIX C

INFORMED CONSENT FORM

 INFORMED CONSENT DOCUMENT

Project Title: Attitudes towards Help-Seeking among South Asian American

Muslim Women
Research Team: Amina Mahmood, BA

Leslie Leathers, BS
William Liu, PHD
Joy Moel, BA

This consent form describes the research study to help you decide if you want to
participate. This form provides important information about what you will be asked to do
during the study, about the risks and benefits of the study, and about your rights as a

research subject.
• If you have any questions about or do not understand something in this form, you
should ask the research team for more information.
• You should discuss your participation with anyone you choose such as family or
friends.
• Do not agree to participate in this study unless the research team has answered
your questions and you decide that you want to be part of this study.

WHAT IS THE PURPOSE OF THIS STUDY?

This is a research study. We are inviting you to participate in this research study
because you are: 1) female, 2) between the ages of 20-35, 3) you identify yourself as
South Asian American Muslim.

The purpose of this research study is to learn about 1) psychological health

concerns faced by South Asian American Muslim women, 2) definitions of and attitudes

towards seeking help for these concerns, 3) and the impact of religious and cultural
beliefs on how psychological health concerns are defined and where help is sought to
address these concerns.
 136

HOW MANY PEOPLE WILL PARTICIPATE?

Approximately 20 women living in the United States are expected to participate in

this study.

HOW LONG WILL I BE IN THIS STUDY?

If you agree to take part in this study, your involvement will last for
approximately one to one and a half hours.

WHAT WILL HAPPEN DURING THIS STUDY?

Location: This study will be conducted at a conference room at the local public
library, however, you may choose another location if this is inconvenient for you.

Demographic Questionnaire: You will be asked to provide some information

about yourself by answering questions on a form. You will be asked about your
educational level, occupation, income, age, number of children, marital/partner status,
ethnic background, and religious identification.

Interview: You will be asked 10 questions about 1) psychological health concerns

faced by South Asian American Muslim women, 2) definitions of and attitudes towards
seeking help for these concerns, 3) and the impact of religious and cultural beliefs on how
psychological health concerns are defined and where help is sought to address these
concerns. The interview will be audio taped for later transcription.

You are free to skip any questions on the questionnaire or during the interview
that you would prefer not to answer. Participation is voluntary and you may end your
participation at any time

Audio Recording
One aspect of this study involves making audio recordings of the interview. This
is done to ensure accurate transcription of your answers. Only the researchers will have
 137

access to the recording. These recordings will be destroyed 3 years after the study has

been completed.

WHAT ARE THE RISKS OF THIS STUDY?

You may experience one or more of the risks indicated below from being in this
study. In addition to these, there may be other unknown risks, or risks that we did not
anticipate, associated with being in this study.
You may be uncomfortable talking to the researchers about personal matters.
You may skip any questions you do not wish to answer and you may end your
participation at anytime.

WHAT ARE THE BENEFITS OF THIS STUDY?

We don't know if you will benefit from being in this study. However, we hope
that, in the future others might benefit from this study because the information you will
provide will add to the research literature on an underrepresented population (that is,
South Asian American Muslim women) and the information may help professionals
working with South Asian American Muslim women.

WILL IT COST ME ANYTHING TO BE IN THIS STUDY?

You will be responsible for the cost of travel and/or parking to the interview
destination at the local public library. You may request that the interview take place at a
location that is convenient for you.

WILL I BE PAID FOR PARTICIPATING?

You will not be paid for being in this research study.

WHO IS FUNDING THIS STUDY?

The University and the research team are receiving no payments from other agencies,
organizations, or companies to conduct this research study.
 138

WHAT ABOUT CONFIDENTIALITY?

We will keep your participation in this research study confidential to the extent

permitted by law. However, it is possible that other people such as those indicated below

may become aware of your participation in this study and may inspect and copy records

pertaining to this research. Some of these records could contain information that

personally identifies you.

• federal government regulatory agencies,
• auditing departments of the University of Iowa, and
• the University of Iowa Institutional Review Board (a committee that reviews and
approves research studies)

To help protect your confidentiality, we will assign you a participant number and
a false name in order to keep your records confidential. The study participant number and
false name will not be linked to your name. Additionally, we will not include the names
of family members, friends, and other identifiable locations (for instance, workplace) that
can personally identify you in the reports of the study. All tapes, transcripts and
demographic questionnaire forms will be kept in a locked file, and all computer files will
be password protected. If we write a report or article about this study, we will describe
results in a summarized form so that you cannot be identified.

IS BEING IN THIS STUDY VOLUNTARY?

Taking part in this research study is completely voluntary. You may choose not
to take part at all. If you decide to be in this study, you may stop participating at any
time. If you decide not to be in this study, or if you stop participating at any time, you
won't be penalized or lose any benefits for which you otherwise qualify.

WHAT IF I HAVE QUESTIONS?

We encourage you to ask questions. If you have any questions about the research
study itself, please contact: Amina Mahmood at 813-531-6863 or amina-
 139

[email protected]. If you experience a research-related injury, please contact Dr.

William Ming Liu at 319-335-5295 or [email protected]

If you have questions, concerns, or complaints about your rights as a research

subject or about research related injury, please contact the Human Subjects Office, 340
College of Medicine Administration Building, The University of Iowa, Iowa City, Iowa,
52242, (319) 335-6564, or e-mail [email protected]. General information about being a
research subject can be found by clicking "Info for Public" on the Human Subjects Office
web site, http://research.uiowa.edu/hso. To offer input about your experiences as a
research subject or to speak to someone other than the research staff, call the Human
Subjects Office at the number above.

This Informed Consent Document is not a contract. It is a written explanation of

what will happen during the study if you decide to participate. You are not waiving any

legal rights by signing this Informed Consent Document. Your signature indicates that

this research study has been explained to you, that your questions have been answered,

and that you agree to take part in this study. You will receive a copy of this form.
 140

Subject's Name (printed):

Do not sign this form if today's date is on or after $STAMP_EXP_DT .

(Signature of Subject) (Date)

Statement of Person Who Obtained Consent

I have discussed the above points with the subject or, where appropriate, with the
subject's legally authorized representative. It is my opinion that the subject understands
the risks, benefits, and procedures involved with participation in this research study.

(Signature of Person who Obtained Consent) (Date)

 141

APPENDIX D

INITIAL INTERVIEW PROTOCOL

 142

Preliminary Interview Protocol

South Asian American Muslim Women

1. What constitutes good psychological health and well-being/overall health and

wellbeing for you?
2. To what extent are these definitions influenced by your cultural background? By
your religious background? Is there an area of overlap between your religious and
cultural beliefs and values?
3. What types of problems/concerns issues that you or others of your religiocultural
background have faced/are facing?
4. When you or others of your religiocultural background are experiencing
psychological distress/imbalance in health and wellbeing, what are the steps taken
to alleviate the distress/achieve balance?
5. How does your culture view psychological distress? What about your religion?
(Probe for areas of overlap, and differences)
6. What are your views on help-seeking? Definition of help-seeking? Do these differ
from your cultural/religious upbringing?
7. How do you/ your relgiocultural community view going to a psychologist/mental
health care provider for some of the aforementioned health concerns you
identified?
8. What resources does your religiocultural community have available for
individuals going through some of the issues you identified? For instance: is help
sought from elders, religious leaders, hakims (traditional healers).
9. What would prevent you or others from your community from seeking help from
a psychologist and/or other mental health care provider? What would facilitate
seeking help from a psychologist and/or other mental health care provider?
Is there anything else you would like to add?
 143

APPENDIX E
DEMOGRAPHIC FORM AND FINAL INTERVIEW PROTOCOL
 144

Demographic Form

Background Information:

Age:
Ethnic Background (e.g. Pakistani American, Indian American etc.):

How long have you lived in the United States:

Religious Identification (e.g. Muslim, Sunni Muslim, Shia Muslim etc.):

What is your marital status? (circle one):

1 Married 2 Separated 3 Divorced
4 Widowed 5 Single, not in a relationship
6 Single, but with opposite sex partner 7 Single, but with same sex partner
8 Refused

How many people live in your household?

Who lives in your household (e.g. parents, children, husband, partner):

How many children do you have?

What is your current occupation (including working in or outside the home, e.g.
housewife, self-employed, retail, construction etc.):
 145

What is your approximate total household income per year (circle one)? (Include all
sources, such as child support or alimony)

1 --$9,999 or less 7--$60,000-$69,999

2~$ 10,000-$ 10,999 8-$70,000-$79,999
3--$20,000-$29,999 9-$80,000-$89,999

4 - $30,000-$39,999 10-$90,000-$99,999

5-$40,000-$49,999 11—$100,000 or more

6-$50,000-$59,999 12—Refuse

What is the highest level of education you have completed? (e.g. 11th grade,
Associate's degree, Junior year college, graduate degree, vocational degree, etc.):
 146

INSTRUCTIONS: Use the scale below to indicate the extent to which you agree

with the value expressed in each statement.

1 = Strongly Disagree

2 = Disagree

3 = Agree

4 = Strongly Agree

1. One should not deviate from familial and social norms.

2. Children should not place their parents in retirement homes.

3. One need not focus all energies on one's studies.

4. One should be discouraged from talking about one's accomplishments.

5. Younger persons should be able to confront their elders.

6. When one receives a gift, one should reciprocate with a gift of equal or
greater value.
7. One need not achieve academically in order to make one's parents proud.

8. One need not minimize or depreciate one's own achievements.

9. One should consider the needs of others before considering one's own needs.

10. Educational and career achievements need not be one's top priority.
11. One should think about one's group before oneself.
12. One should be able to question a person in an authority position.
13. Modesty is an important quality for a person.
14. One's achievements should be viewed as family's achievements.

15. One should avoid bringing displeasure to one's ancestors.

16. One should have sufficient inner resources to resolve emotional problems.
17. The worst thing one can do is to bring disgrace to one's family reputation.
18. One need not remain reserved and tranquil.
19. One should be humble and modest.

20. Family's reputation is not the primary social concern.

21. One need not be able to resolve psychological problems on one's own.
22. Occupational failure does not bring shame to the family.
23. One need not follow the role expectations (gender, family hierarchy) of
one's family.
24. One should not make waves.

25. One need not control one's expression of emotions.

 Religious Commitment Inventory - 10

Please respond to the following using the following scorin

1 = NOT AT ALL TRUE OF ME

2 = SOMEWHAT TRUE OF ME

3 = MODERATELY TRUE OF ME

4 = MOSTLY TRUE OF ME
5 - TOTALLY TRUE OF ME

1. I often read books and magazines about my faith.

2. I make financial contributions to my religious organization.

3. I spend time trying to grow in understand of my faith.

4. Religion is especially important to me because it answers

many questions about the meaning of life.
5. My religious beliefs lie behind my whole approach to life.

6. I enjoy spending time with others of my religious affiliation.

7. Religious beliefs influence all my dealings in life.

8. It is important to me to spend periods of time in private
religious thought and reflection.
9. I enjoy working in activities of my religious organization.
10.1 keep well informed about my local religious group and
have some influence in its decisions.
 Moslem Attitude towards Religiosity Scale (MARS)
Please respond to questions using the following scoring:
1 = Strongly Disagree
2 = Moderately Disagree
3 = Neutral

4 = Moderately Agree
5 = Strongly Agree

1. I find it inspiring to read the Qu'ran

2. Allah helps me.

3. Saying my prayers helps me a lot.

4. Islam helps me lead a better life.

5. I like to learn about Allah very much.

6. I believe that Allah helps people.

7. The five prayers help me a lot.

8. The application (dua) helps me.

9. I think the Qu'ran is relevant and applicable in

modern day.

10.1 believe that Allah listens to prayers.

11. Mohammed (peace be upon him) provides a good

mode of conduct for me.

12.1 pray five times a day.

13.1 fast the whole month of Ramadan.

14.1 observe my daily prayers in the Mosque.
Think of this ladder as representing where people stand In the United States.
At ins lop of the ladder are the people who are lie best off -< those who have the most money,
the most education and the mostrespectedjobs. At the bottom are the peple who aw the
worst off - who have the least money, least edycatlon, and the least respected jobs or no job.
The higher up you are on this ladder, she closer you are to the people at the very top;
the lower you are, the closer you are to the people at the very bottom.

Where would you place yourself on this ladder?

Please place a large HX" on the rung where you think you stand
at this time in your life, relative to other people in the United Stales,
 151

Semi-Structured Interview Protocol

1. I am going to ask you several questions re: psychological/emotional health and

wellbeing and would like you to answer by keeping your cultural group (e.g.
Bengali American Muslims) and religious background in mind. You identify as
Muslim, what cultural/ethnic group do you identify with?

2. What does being psychologically healthy mean to you? How would you know if
someone is experiencing psychological difficulties? What does your culture say
about psychological health and wellbeing? What does your religion say about
psychological health and wellbeing?

3. When thinking of others in your family/acquaintance/community from your

culture (replace "culture" with participant's term e.g. Pakistanis), how would they
define psychological health/wellbeing? Would the definition be similar or
different? Would it be different if they belonged to a different religious group?

4. Are there concerns you've noticed coming up for yourself, your family, your
friends, or others in your cultural group (e.g. Indian American), regarding their
psychological health? Are these concerns/issues similar to one's experienced by
members of your religious group?

5. You talked about (repeat back issues/concerns stated in response to previous

question), when either people you know personally or others (in your cultural or
religious group) are facing these concerns/issues, what are some of the things that
they might do to feel better, or resolve the concern/issue. {If asked to clarify, for
example, sometimes people talk to a trusted friend, others choose to pray, or talk
to a religious leader, consulting a hakim/traditional healer, some talk to a
counselor}.

6. Would you, your family, or friends ever consider seeing a psychologist or other
mental health care provider? If so, what would you/they see the
psychologist/mental health professional for? If not, why not?

7. Would other {ethnic group} Muslims consider seeing a psychologist/mental

health professional? If so, what are some issues/concerns they would bring to the
psychologist/mental health provider? If not, why not?
 152

8. What would prevent you or others in your community from seeing a psychologist
and/or other mental health care provider?

9. What would make it easier for you or someone of your cultural and religious
background to seek professional help (that is, psychologist or other mental health
care provider)?

10. What is your perception of psychologists/other mental health care providers?

What could psychologists/other mental health care providers do to make seeking
psychological/mental health care services more acceptable among members of
your cultural and religious group?

Thank you very much for your time. Is there anything else you would like to
add? Are there any questions you might have for me?

Debriefing Statement: This study will help us to better understand the

attitudes and perceptions of South Asian American Muslim women towards help-
seeking. We hope that this research study will add to the research base on South
Asian American Muslim women and assist psychologists and other mental health care
providers in better addressing the needs of this population.
 153

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