by Zainab Saherwala, DO; Sabina Bashir, BA; and Danielle Gainer, MD

Drs. Saherwala and Gainer and Student Doctor Bashir are with Wright State University in Fairborn, Ohio.

FUNDING: No funding was provided for this study.

DISCLOSURES: The author has no conflicts of interest relevant to the content of this article.

ABSTRACT: Providing culturally competent care for Muslim women poses specific challenges to the mental health provider. The importance of recognizing the strong link of postpartum depression, stigma against mental illness and medications, unique cultural beliefs, effect of discrimination, and emphasis on modesty in this patient population can serve as important tools in understanding the patient and establishing patient–provider alliance. This article will review and analyze illustrative cases related to the mental health treatment of Muslim women as well as the approach that providers can utilize to deliver culturally competent treatment for this patient population.

Keywords: Cultural competence, Muslim women, postpartum depression, immigrant women

Innov Clin Neurosci. 2021;18(4–6):

Muslims are a growing religious minority in the United States today.1 As of 2011, approximately 7 to 10 million American Muslims resided in the United States (US), and this estimate has steadily increased since then.2 Despite being relatively well-integrated among western society, American Muslims often continue to be misunderstood and misrepresented,2 particularly in healthcare settings. A lack of knowledge and understanding from non-Muslim providers can be detrimental to Muslims, especially in the setting of mental healthcare and treatment.3

Islam involves rich cultural and religious beliefs and traditions that shape the perspectives and lifestyles of Muslims in every aspect of their lives.3 The foundation of Islam is based on the five pillars: Shahadat (Faith), Salat (Prayer), Zakat (Charity), Saum (Fasting), and Hajj (Pilgrimage to Mecca).2 The foundation of these beliefs influences decision-making, family dynamics, health practices, and the use of healthcare.4 Additionally, there are several subgroups and ethnicities within the Muslim community that have diverse views and opinions regarding illness and healthcare, which can pose additional challenges for non-Muslim mental healthcare providers unfamiliar with their beliefs.4 These differences include, but are not limited to, ideas of modesty, privacy, and diet.4 It is also important to note that American Muslims might adhere to values and traditions that stem from cultural roots rather than religious ones.2 Overall, Islam truly plays a crucial role in shaping the lives of Muslims and an understanding of this fact is the basis for providing culturally competent mental health treatment for Muslim patients. 

Unfortunately, there is a lack of data regarding the prevalence of psychiatric disorders in Muslims living in the US.5 Common mental health problems reported by Muslims working within the Muslim community on issues of mental health in the US included disorders related to marital problems, substance use disorders, and sexual activity.6 Furthermore, mental health providers often encounter patients who are from different cultural backgrounds, and these patients can be challenging to diagnose and treat due to a potential lack of familiarity with their traditional, cultural, and religious views. While the mental health profession continues to serve diverse patient populations, women within the Muslim population specifically remains underserved.2 

Lack of knowledge about Islamic culture can act as an impediment in Muslim women’s healthcare.8 Thus, healthcare professionals should be aware of cultural and religious factors that help provide culturally competent and appropriate promotion and education of health services to the Islamic population.6 With recognition and understanding of the unique cultural aspects and religious beliefs that Muslim women practice, mental health providers can learn to become culturally competent at providing mental health care for this patient population.


CASE VIGNETTE 1

“Mrs. P, a 34-year-old, married, Arab female individual presents to Dr. S’s office for the chief complaint of “anxiety and increased tearfulness in the past six months.” When Mrs. P enters the clinic, she begins the interview crying. She states, “I feel like a failure because I’m not able to conceive. I was diagnosed with a condition called polycystic ovary syndrome, and my doctor said that my hormones are out of balance, and this can affect my fertility.” Mrs. P continues by saying, “I don’t know how to answer when my mother-in-law and extended family ask why my husband and I have not had children yet.” Dr. S empathetically listens to Mrs. P and asks if she has been referred to see a fertility specialist. Upon hearing this suggestion, Mrs. P appears taken aback and states, “How could you say that? My infertility is due to Allah’s will, and I cannot challenge his will by taking medications! I have been suggested to eat honey daily, and constantly pray to Allah to forgive my sins and give me children…”

Practice point: Muslim women who experience infertility are at greater risk of developing mental health conditions. 

A strong familial unit is extremely important in Islamic culture.4 According to Islamic culture, it is the duty of Muslim women to be the fundamental guardian of the household and their children.9 Infertility is a particularly devastating condition for Muslim women, as a woman’s worth in many Muslim cultures is measured by her ability to bear children.9 Culturally, Muslim women feel a high obligation to bear children, and infertility could cause women to question self-worth when they struggle with fertility.9 After marriage, there might be significant pressure for a Muslim woman to bear children, and infertility might induce symptoms of mental illness.9 Additionally, since Muslim culture is that of collectivism, Muslim patients might view their concerns as affecting the larger family system as a whole, rather than just themselves.10 Ultimately, these factors could compound stress and pressure on a Muslim woman, potentially leading to negative outcomes, such as the development of a perinatal mental illness.11 Mental health professionals should remain aware of the importance of family involvement and the impact it could have on mental health.11 The cultural values of the family as a whole have an impact on the assessment of patients’ needs; thus, it is important to involve family in the care of the patient.4 

Muslims can also view illness or health concerns as a “test from God,” which subsequently encourages them to turn to Allah for prayers and forgiveness of sins, as a hope to cure illnesses.4 Although infertility treatment and western medical care is not discouraged from Islam, traditional medical practice in Islam encourages use of natural remedies that are mentioned in the Quran, such as use of honey, or nigella seeds, and focus on prayers to cure illness.12 Additionally, negative attitudes toward contraception and fertility control in this patient population are affected by wider sociocultural and religious factors and might impact use.13

A mental health provider treating a Muslim woman struggling with infertility, particularly one who places high regard on traditional Islamic methods of curing illness, might wish to consider the following concepts. First, the mental health provider’s role is to first recognize the unique emotional burden that infertility can pose on Muslim women. The mental health provider should adopt a nonjudgmental stance toward traditional medical practice and avoid assumptions that a patient will unquestionably seek fertility treatment and medications. Second, the provider should use supportive psychotherapy and empathy to promote an environment where the patient will feel comfortable discussing her religious/cultural beliefs regarding infertility and discuss the unique emotional burden that the patient feels regarding her concerns about this issue. Once empathy and patient alliance are established, the mental health provider can ask an open-ended question, such as “What do you believe your options are for treatment on your condition?” Open-ended questions will prevent the provider from making assumptions about the patient’s views and could provide a valuable opportunity to gain a window of insight into the patient’s beliefs.


CASE VIGNETTE 2

Mrs. R, a 28-year-old Afghani female who recently moved to the US two years ago, apprehensively walks into Dr. G’s office this afternoon with her husband. Her obstetrician-gynecologist (OB-GYN) referred her to see a psychiatrist for complaint of “loss of appetite, increased guilt/hopelessness, and withdrawal from family and friends for six months after delivering her baby.” On her mental status exam, Mrs. R speaks softly, looking down at the ground when she speaks to the provider, and has dark circles under her eyes. When Dr. G asks what brings Mrs. R in, she responds by stating, “I was so excited to have a baby, but I have been possessed by a Jinn that won’t allow me to make milk to feed my baby. It whispers in my ear at night and tells me not to pray and to ignore my duties as a mother.” As the psychiatric interview progressed, it was discovered that Mrs. R has poor social support in the US, as her entire family is back in Afghanistan. Dr. G diagnoses Mrs. R with postpartum psychosis and encourages her to be psychiatrically hospitalized and started on antipsychotics. Mrs. R and her husband appear highly anxious, immediately reject this plan, and try to leave the psychiatry clinic. 

Practice point: Mental health professionals should be aware that the prevalence of postpartum depression (PPD) in Asian cultures is as prevalent as in European cultures, and that this is a condition that can affect Muslim women, notably Muslim immigrants with poor social support.14

The prevalence of PPD has been reported to be from 0.5 to 60 percent globally, and from 3.5 to 63.3 percent in Asian countries, in which Malaysia and Pakistan had respectively the lowest and highest rates.15 To study of the prevalence of PPD in Muslim women, a literature review analyzing the data from over 22 Middle-Eastern/Arabic countries determined that that the prevalence rate of PPD in Middle Eastern/Arabic women ranged variably from 10 to 51.8 percent.16 Currently, there are limited studies conducted measuring the occurrence of PPD in Muslim Immigrant women in the US. However, a few studies have examined the factors contributing to PPD in Muslim women who have migrated from Muslim countries to Western Countries. In a study conducted by Small et al,17 Turkish women who immigrated to Australia and were diagnosed with PPD were noted to have increased social isolation, felt homesick, and unsupported.

Muslims believe in the “Jinn” (or devil), which can tempt Muslims to follow “different paths.”11 There is no literature to support that Jinn possession causes mental illness; however, some Muslims have the belief that the Jinn can cause emotional and physical distress at times of vulnerability, such as the postnatal period.18 Studies have shown that descriptions of Jinn possession “clearly mirror the symptoms of postnatal depressive disorder in Western Cultures.”18 Mothers will feel sad, anxious, and physically exhausted, often blaming themselves for the “possession” and feeling powerless in escaping it. An inability to breastfeed might also predispose a Muslim woman to feel as though she is not fulfilling her religious duties while failing to provide her child with the best nutrition as recommended by guidelines.11 These tensions could culminate in low self-esteem and perinatal mental health problems.11

span class=”s1″>Mental health practitioners should remain aware of the concept of “Jinn Possession,” given the rise of multiculturation and immigration. Mental health providers should first adopt a practice of researching concepts of possession when approaching a Muslim patient, as this is not a unique concept among Islam. Awareness of this phenomenon within this population allows for some ease in determining a treatment plan and establishing alliance with a patient. If Dr. G asks the patient and her husband additional questions regarding Jinn possession, specifically if this is a common occurrence among her culture in Afghanistan, the psychiatrist would play an important role in acknowledging the grief that Mrs. R is experiencing and gain insight into her psychiatric condition. By empathizing with Mrs. R and understanding that lack of social support and isolation from her community are factors that worsen her prognosis, the provider could suggest medication, referrals for psychotherapy, and propose involvement of the patient’s religious community as options for treatment. Ultimately, any underlying mental health problem should be treated by usual psychiatric methods, but the clinician should respect the cultural issues and avoid directly contradicting statements from the patient or relatives about the reality of possession.6 Additionally, for patients with the belief of Jinn possession, there might be a strong indication for involving a religious leader in the management of these cases.6

CASE VIGNETTE 3

Dr. B, an emergency room (ER) psychiatrist, looks at the electronic medical record to find a new patient in Room 1 with the chief complaint of “suicidal ideation.” The nurse approaches Dr. B and states, “the patient in Room 1 is not listening to us, Dr. B. I tried giving her paper scrubs, but she is being noncompliant.” Looking over patient M.M.’s chart prior to entering the room, Dr. B noticed a red flag at the top of the page. The red flag reads in bold font “patient requests to see a female provider only.” “Hmm, that’s odd,” Dr. B thinks to himself. Dr. B enters the room to find M.M., a female patient wearing a purple head scarf, concealing her hair, and a long, black dress covering her arms and legs. Unlike most of Dr. B’s patients, M.M. is not dressed in the paper gown that the nurses provide for patients in the emergency psychiatric unit. Dr. B, confused by the patient’s refusal to wear the gown, wonders how he can at least convince M.M. to take off the head covering, as it poses a suicide risk for her while waiting to be admitted to the inpatient psychiatric unit. 

Practice point: Modesty is a significant component of Islam. The Islamic faith encourages Muslim women to place emphasis on modesty in dress and behavior, fertility, and strong family relationships.4,9 

Modesty and privacy of a Muslim woman must be respected at all times, as it is necessary to maintain moral and social order.4 Muslim dress varies based on the patient’s country of origin, but a commonality shared is that a woman’s arms, legs, and hair should be covered to maintain a conservative appearance while in public.4 As this concept translates to medicine, Muslim women might feel extremely uncomfortable wearing the revealing hospital provided gowns that have become commonplace in Western hospital settings.4 While admitted to an inpatient psychiatric unit for example, providers should first understand the nature of this discomfort and explore alternative, safe clothing options for patients.19 Ideally, it is also best if a Muslim woman is cared for by a same-gender mental healthcare provider, if possible.4 

Both men and women have a duty to remain modest; however, those unfamiliar with Islam most often associate modesty with Muslim women, as evidenced by the practice of covering the hair/body in public settings.14 The hijab is a traditional head covering that Muslim women wear to conceal their hair, thus concealing a symbol of sexuality. Islam as a religion does not force Muslim women to wear religious head coverings, and women in the US display a personal preference to wear them when in public. Overall, modesty can be reflected in the way a Muslim woman dresses and behaves in their everyday life.

This vignette demonstrates the fact that often Western medicine practices do not adhere to such Islamic norms, especially that of modesty.19 Most hospital and clinic settings offer gowns that can be too revealing and uncomfortable for a Muslim woman to wear, even in the privacy of a private room. Like most psychiatrists, Dr. B is focused on maintaining the safety of M.M. and the apparent hanging risk that a loose article of clothing, such as a hijab, would pose on a patient. Dr. B would likely benefit by approaching the situation from a place of understanding the cultural significance of the hijab. Muslim women should be allowed to keep their hijab and any articles of clothing on in which they feel most comfortable, which will ultimately facilitate the development of a trusting physician-patient relationship.14 Although it might appear that wearing a hijab will be a hindrance to safety, it can facilitate the healing process for M.M., as it will allow her to maintain her spirituality and connection with Allah. Islam itself can be considered a pillar of strength and healing as it relates to M.M.’s mental health.10

CASE VIGNETTE 3, CONTINUED

“Good morning, M.M. It is so nice to meet you!” Dr. B states. “Hello, doctor, it is nice to meet you as well,” states M.M. Dr. B notices that M.M appears uncomfortable after he stepped in the room, and that there is a man sitting in the corner of the room. Before Dr. B could ask, M.M. shares that she brought her husband and that she would like him to stay in the room for the psychiatric evaluation. Dr. B begins gathering history. A few questions later, M.M. does not answer on her own and instead turns to her husband seemingly for support. For the rest of the interview, M.M.’s husband answers the questions for her. “I guess she is just shy,” thinks Dr. B. Due to having many other patients to see in the ED, Dr. B does not ask M.M. to change into the paper gown. Dr. B collects the information he needs, and since M.M. and her husband do not have any questions for him, he politely leaves the room and starts writing his note: It is apparent that M.M. is exhibiting signs and symptoms of a depressive episode as well as suicidal ideation, and she will need to be admitted to the psychiatric inpatient unit for a few days to get stabilized on the proper medication. “That was odd. I’ve never had a patient that just lets her husband take over the conversation like that,” Dr. B thinks to himself. 

Practice point: Modesty can translate into the clinical sphere by a patient requesting a same-gender provider. In general, Muslim women prefer to be seen by a female healthcare provider.14 

As it relates to psychiatry specifically, Muslim women prefer a female mental health provider because it would violate the principles of modesty and conservatism to be alone in a room with a male physician or psychotherapist who is not her relative.14 Such a request can be due to both cultural and religious preferences. If it is not possible for a Muslim woman to see a same-gender provider, it can be customary for her husband or male relative to accompany her to her appointments.20 It is also common for husbands or male relatives to answer questions for the female patient. This act can sometimes appear too controlling or dominating and can contribute to the reason Muslims are often misunderstood and in general, negatively stereotyped in Western cultures.13 At times, the Western healthcare provider might interpret the Hijab and traditional Islamic views as oppression; however, for Muslim, women modesty can be interpreted as a liberating experience and provides them with empowerment regarding the ability to make autonomous healthcare decisions.20

Western medicine can also affect Muslim values of modesty through patient–provider interactions. Eye contact and human touch are two main mechanisms by which providers establish trust and connection with their patients. When interacting with a Muslim patient, however, these cues can sometimes result in negative feelings from the patient. When interacting with a Muslim female patient, male healthcare providers should generally minimize excessive eye contact and physical contact with a female Muslim patient as much as possible.4 Additionally, a male provider should always ask if he has the permission to touch a female Muslim patient prior to examining her, to demonstrate respect for the patient’s cultural beliefs. When working with a female patient, a male provider might have to also communicate through the patient’s spouse. These actions should be interpreted by the provider as modesty, not lack of trust or a sign of rejection towards the provider.4

Practice point: Cultural competency can positively impact the therapeutic relationship.  

Overall, this vignette illustrates how understanding cultural competency and tailoring a situation for a patient’s specific religious needs can promote true understanding and drastically improve the therapeutic relationship. Dr. B should first approach this situation by understanding the cultural and religious contexts of why M.M. would want to continue to wear her hijab and traditional clothing, and secondly determine if the hospital policy/nursing protocol can make some exceptions to the rules to promote cultural competence and ultimately make M.M more comfortable while maintaining safety protocols. Hospitals have a long-standing history of accommodating patient preferences for food and allocating space to meet the spiritual needs of patients, and thus Dr. B could also investigate if the hospital has modest patient gowns or scrubs available for M.M while maintaining safety.19 In short, all healthcare professionals should aim to be empowered with the capacity, knowledge, and skills to respond to the special needs of a Muslim patient.4 


CASE VIGNETTE 4 

“Ugh, not her again. She just doesn’t understand what I try to tell her,” grumbled Dr. J to herself. Glancing at patient K.B.’s chart, Dr. J becomes frustrated in anticipation of a long clinic appointment. K.B. is a 26-year-old female individual who just recently moved from Pakistan, and today is K.B.’s second appointment with Dr. J. 

Dr. J enters the room, politely greets K.B. and her newborn son whom she brought with her and begins to ask her the standard set of postpartum questions. When asked about feelings of sadness, K.B. pauses, holding back tears. “I…I… miss my mother…,” K.B. softly admits. “Here we go again…she didn’t even understand what I asked her. What in the world does her mother have to do with her own feelings?” thinks Dr. J.

Practice point: A solid familial unit is an important backbone of support in Islamic culture; however, many immigrant postpartum Muslim women have little social support. 

Traditionally, Muslim women obtain a 40-day postpartum rest period while her family, especially her mother, provide support at home for the new mother and baby.21 This tradition is typically lost for immigrant Muslim women who are geographically separated from family. The stress of parenting in a different cultural and religious context without support and guidance from extended family members might result in feeling overwhelmed and isolated and lacking confidence in parenting abilities.2 In addition to the stress of being an isolated new mother, the stress of household duties (such as providing for her husband and other children at home) can compound these negative emotions. 


CASE VIGNETTE 4, CONTINUED

Dr. J ignores K.B.’s comment and continues with her history taking. K.B. shares that for the past month after delivery, she has been struggling with feelings of sadness, worthlessness, anhedonia, decreased energy, disturbed sleep, and decreased appetite. K.B. also feels intense feelings of loneliness and shares that she has not made any friends with whom she can truly connect with because there is no mosque nearby. K.B. spends most of her time at home taking care of her son, and Dr. J realizes that she appears overwhelmed. 

Practice point: Life as an immigrant can be extremely challenging, and immigrant Muslim women often also experience significant challenges overcoming language and communication barriers. 

As emphasized above, Muslim women traditionally have tremendous amounts of domestic responsibilities.11 With these responsibilities in their minds, Muslim women who are immigrants to the US might face additional challenges, such as marginalization, discrimination, racism, and struggles with acculturation.10 As with most individuals who immigrate to the US, a change in family roles can be quite disruptive.10 Difficulty learning the English language and limited or nontransferrable job skills also present challenges for Muslim immigrants who are trying to start a new life in the US.10 Limited research has been conducted regarding help-seeking behavior in Muslim immigrants, but reasons for this underutilization of services can relate to both the stigma of mental health in Muslim culture and cultural mistrust of mental health providers.10 

As an immigrant from Pakistan, K.B. is succumbing to the pressure of being a new mother and has trouble communicating this to her mental health provider. Loss of status in a Western society can lead to feelings of isolation and marginalization.10 Like K.B., Muslim patients might feel an additional degree of isolation from Western society due to a lack of understanding and empathy on the part of the mental health provider. The stressors of being an American Muslim immigrant are often manifested in the form of psychological distress.2 Because of this, providers should utilize empathy and understanding when specifically treating immigrant Muslim women, as the added stress of being an immigrant can negatively affect mental health. 

Although many women might feel an overwhelming sense of responsibility to their newborn, religious obligations associated with being a new mother can be perceived as additional pressure when a woman first enters motherhood.11 This could subsequently contribute to Muslim women suffering from low self-esteem and thus a risk of developing perinatal mental illness.11 This seemingly constant cycle of isolation and stress are a major risk factors for development of PPD in Muslim women.22

K.B. is suffering from PPD, and the clinical encounter is further challenged by Dr. J’s frustration regarding communication difficulties. In a systematic literature review analyzing 29 articles, Rodrigues found that due to a significant language barrier, immigrant Muslim women were observed to seek advice from family, friends, and religious leaders on issues regarding healthcare.8 This hesitancy of seeking help from a mental health profession could lead to further delay in receiving treatment and could worsen the prognosis and outcome of PPD. 

Dr. J could improve patient alliance if she approached the situation in a highly supportive and personalized manner. Although all patients require a personalized management plan, treating a Muslim immigrant adds another layer of complexity to treatment. Effective treatment plans for American Muslims are based on thorough and culturally responsive assessments.2 Since Islamic practices are so integral in everyday life, K.B. will benefit significantly from a spiritually based and culturally sensitive climate throughout treatment. Dr. J and the rest of her clinical staff could also improve this situation by familiarizing themselves with some of the basic Islamic religious and cultural principles to establish a framework of care from an Islamic perspective. Furthermore, they can seek a language translator for the psychiatric interview if there is a perceived communication issue.13 

Overall, this case emphasizes that mental health professionals should be aware of the importance of the whole family unit in Islam, the challenges surrounding being a Muslim immigrant, and the importance of recognizing communication barriers in providing competent care for Muslim women.

CASE VIGNETTE 5

Ms. F, a 22-year-old Iraqi female, presents to the inpatient psychiatric unit for bipolar disorder, current episode manic, as she has been nonadherent with lithium for the past two weeks. Over the course of her admission, Dr. N prescribes Lithium 600mg three times a day (TID) for this patient but notes that the patient has been nonadherent with her morning and afternoon doses. However, Ms. F agrees to take medications that are administered to her in the evenings. Additionally, nursing staff documents that Ms. F has “poor food/water intake, declines to order breakfast and lunch, and eats minimal portions of her dinner every evening. Last night, the patient refused jello and turkey, and only ate three crackers.” With this information, Dr. N, decides to order olanzapine in the evenings to stimulate Ms. F’s appetite and promote weight gain. After one or two days of rapidly titrating olanzapine along with prescribing lithium, Ms. F became hypotensive and complained of significant dizziness. 

During the treatment team meeting, nursing staff reports to Dr. N that Ms. F “has been knocking on the nursing station window asking for a Quran. She is always found in her room bowing and rocking on the ground, facing the wall, whispering Arabic to herself, and prays in the middle of the night. Dr. N concludes that Ms. F continues to present manic with psychotic symptoms and will need to be involuntarily committed through a court order due to nonadherence with medications and poor oral intake.

Practice point: Ramadan can pose challenges in psychiatric medication adherence. Mental health providers should be aware of the fasting window during Ramadan, emphasis of prayer during this holy month, and the general dietary restrictions/limitations in Islam. 

This case describes Ms. F, a Muslim woman who was admitted to the inpatient psychiatric unit during the Holy Islamic month of Ramadan. In Islam, Ramadan is viewed as the most sacred month of the Islamic year.7 The dietary practice of fasting during Ramadan requires participants to consume one meal before sunrise (Suhoor) and large meal following sunset (Iftaar) to break the fast.7 During the fasting window, Muslims should refrain from eating, drinking, and practicing in sexual activity or sinful behavior. Additionally, Muslims often do not take oral medications during the fasting period. The purpose of the month-long fast is for Muslims to further commit themselves to Allah, or God. Although this religious holy event is well known to non-Muslims, many Western medicine practices are not tailored to meet the needs of Muslim patients during this time.7 

Dr. N was not aware of Ms. F’s cultural and religious practices during this month. Ms. F’s refusal to take lithium during the fasting window, and emphasis on prayers (reading the Quran and praying throughout the evening), is a typical practice for Muslims during the month of Ramadan, as the devotion to Allah during this holy month is the most significant goal for Muslims. The psychiatrist and nursing staff did not realize that the patient’s high regard toward praying was attributed to her traditional religious practices, rather than symptoms of mania or psychosis. Although religious grandiosity and preoccupation are common symptoms of acute mania, it is imperative for mental healthcare providers to recognize that this might not be the case, especially when caring for a Muslim patient. An open and nonjudgmental conversation could have allowed Dr. N to understand that Ms. F’s behaviors are consistent with her religious practices instead of being viewed as “nonadherent” or manic behaviors. 

In terms of medication, Dr. N decided to add olanzapine to Ms. F’s regimen because she was not taking her daytime medications and displayed poor oral intake. Dr. N should explore Ms. F’s resistance toward taking medications during certain periods of the day. With this approach, Dr. N would be provided an opportunity to understand the patient’s religious practices. He could then work with Ms. F to promote medication adherence given her fasting in Ramadan and minimize unnecessary medication-induced adverse effects. To provide the optimal treatment for a psychiatric patient hospitalized during Ramadan, oral and injectable medication administration times require adjustment to late evening hours, allowing practicing Muslim patients to abide by their fasting practices.7 Medication titration should be slowed to account for decreased fluid and food intake during Ramadan due to an increased incidence of adverse effects.7

Prayer is an important obligation in Islam, and it is incredibly important during the month of Ramadan. Muslims typically pray five times per day, and this number can often increase during Ramadan as the practice of throughout the night is encouraged. In addition, prayer is an active, involved experience, as there are step-by-step movements that one must perform with their body. For example, Muslims recite prayer verbally while moving from a standing position to bowing down, then placing their head, nose, and palms on the ground. Religion, and specifically prayer itself, can help calm distress in Muslim patients.21 Mental health providers in the hospital should be encouraged to explore religious and spiritual beliefs during the initial psychiatric evaluation to ensure that Muslim patients are able to practice prayers and religious obligations in an accepting environment. 

Halal food is food that adheres to Islamic law regarding the ways in which animals are sacrificed and cleaned.14 The patient in this case did not consume the turkey and jello that was provided by the hospital because there was no guarantee that the food was made in accordance with Halal standards. In the nursing note, it was implied that the patient might be exhibiting signs of disordered eating; however, this patient’s decreased oral intake was likely related to the dietary restrictions of Islam as well as her fasting during Ramadan. Mental health providers should acknowledge the dietary restrictions of Muslim patients and implement sensitivity training amongst nursing staff, nutrition teams, and food preparation staff about Islamic traditions and customs to help maintain cultural sensitivity in food preparation.4,19 Along with this, a dialogue between hospital administrators and community leaders can allow for better assessments of community needs and preferences to identify gaps in current healthcare delivery and enhance trust and communication.19

CASE VIGNETTE 6

Z.B. is an 18-year-old Sudanese female who presents to her high school guidance counselor after the concern from her teachers that she has had poor attendance and decline in her academic performance this past semester. 

Her guidance counselor begins to explore the nature of Z.B’s absences. As her counselor begins to delve into Z.B’s social stressors, it is noted that ZB does not have many friends in high school, and that she does not participate in many extra-curricular activities after school. Z.B. also recently deactivated her social media accounts, including Facebook and Instagram, and is typically observed spending her lunch hour in the library reading books instead of interacting with her peers. 

After obtaining collateral information from Z.B’s mother, her mother states that she has trouble getting Z.B. out of bed in the mornings because Z.B. complaints of stomachaches and headaches and asks to stay home from school. Her mother is concerned that her daughter has lost 10 pounds in the past three months and has periods of extreme irritability and tearfulness at home, which seem to occur out of the blue. 

After some discussion, Z.B. reveals to the school counselor that she is avoiding certain people at school who make fun of her for wearing a hijab and for being Black. She states that the kids at school laugh behind her back, and someone recently slipped a note in her locker that said, “get out of America, you terrorist!” Z.B. states that she feels afraid for her safety at school and feels shame that she looks different from the other girls at school. 

After learning all this information, the school counselor expresses sympathy and reassures Z.B. that “bullying is very common among adolescents, and this will pass soon. After all, you are graduating in six months.”

About two months later, the principal of the school received a request for Z.B. to initiate homeschooling due to her excessive anxiety and inability to cope with stressors. 

Practice point: Racism and discrimination can have a detrimental effect on the health outcomes of Muslim women. 

This case illustrates the specific challenges that a young Muslim female individual might encounter when interacting with peers in educational or occupational settings. As described above, Z.B. is experiencing significant bullying and social isolation based on her race, religion, and physical appearance. While the school counselor attempted to respond to the situation in an empathetic way, there was a lack of awareness of the impact of islamophobia and racism on Z.B.’s daily life. Additionally, there were no proposed steps toward addressing this issue and ensuring that the patient could find comfort in her surroundings. 

Z.B.’s social isolation, affective instability, and poor eating patterns demonstrate the emotional effects of discrimination, which, if not adequately treated, could lead to a significant, detrimental effect on mental health outcomes.1 Although suicide is forbidden in Islam, suicidal ideation and attempts are relatively high in young Muslim women experiencing intergenerational conflict.6 This point further emphasizes the notion that the guidance counselor in this case could have been involved in earlier interventions to alleviate and talk through Z.B.’s negative feelings to avoid potential worse outcomes, such as suicide. 

Since the tragic events of September 11, 2001, Muslims have been subject to heightened discrimination and since then have been often misunderstood within the context of American society.1 In a poll taken directly after 9/11, 60 percent of Americans reported unfavorable attitudes toward Muslims.23 Many Americans associate Muslims with fear-related terms, such as violence, fanatic, radical, war, and terrorism.23 Post‐9/11 events have led to the development of Islamophobia within the US and has been correlated with depressive and anxiety symptoms among Muslims.24 More than 50 percent of the population of Muslim youth in the US report experiencing bullying in schools, and this early exposure to discrimination is likely to have cumulative health effects over the life course.23 Due to discrimination, Muslims can experience increase social exclusion in relation to their cultural and religious identity, which can lead to isolation and exacerbation of mental health disorders.6 Discriminatory assumptions of Muslim women can also interfere with healthcare. For example, in a qualitative study of Iraqi refugees, participants described healthcare providers as unhelpful, patronizing, and having stereotypical attitudes toward Muslim women, believing they are excessively pious, have too many children, and are oppressed by their husbands.23 Thus, religious discrimination is hypothesized to lead to stress, social isolation, reductions in health promoting behaviors, discounting of healthcare providers’ information, and delays in seeking medical care.23

Islamophobia in the US can adversely affect the patient–provider relationship by producing impaired communication, discounted provider information, and reluctance for Muslim women to obtain medical care due to feeling discomfort or judged by their medical providers.23 In general, providers should be aware of the effects that discrimination, racism, and profiling have on Muslim women. Mental health providers are often the first providers that a patient suffering from racism will encounter. Thus, specific interventions should be established to educate mental health providers to recognize signs of discrimination and racism. Once racism is recognized, quality measures should be applied to fix the problem at hand. Given the high frequency of negative stereotyping about Muslims, lack of accurate information about Islam, and changing demographics, it is strongly recommended that educational and mental health facilities expand their diversity training programs.25 For example, programs that include a cultural sensitivity training component can increase understanding of what it might be like to be a marginalized Muslim American individual, whom others often label a “terrorist,” based on their religious beliefs and physical appearance.25 Guidance counselors in schools could incorporate a training exercise of identifying and dispelling myths and misconceptions about Islam as step to prevent racial and religiously based profiling.25 Additionally, eliminating discrimination and increasing the employment of Muslim health care providers and community outreach workers may be one of the most effective ways to reduce health care disparities for Muslims.24 Finally, mental health professionals could collaborate with Imams (Islamic religious leaders) through outreach services to help fulfill a vital role in improving access to appropriate mental health services.6

The current awareness of racism and the research on stigma, discrimination, and health suggest that greater attention needs to be paid to Islamophobia and the role that it can have on the mental health of Muslim women.25 A strong therapeutic alliance and establishment of an empathetic and genuine understanding of what the patient is undergoing is crucial when approaching a patient who is a target of racism.

Conclusion

Caring for the mental health of Muslim women poses unique challenges for providers. A basic understanding of the religious and cultural Islamic practices and their implications on mental health can be beneficial for mental health providers. Many mental health providers in the US are not familiar with the multifaceted role that Islam plays in the daily life of Muslim women, which ultimately can negatively affect the quality of the care they receive. 

Incorporating discussion of cultural competency in mental health is an important part of improving care for patients of all backgrounds and religious beliefs. Acceptance of patients and their own personal beliefs allows providers to strengthen the patient–provider alliance. Maintaining a healthy therapeutic connection is one of the main goals in mental health as it fosters healing and recovery for patients. In conclusion, mental health providers can learn to become culturally competent in caring for Muslim women with understanding of how cultural and religious aspects of Islam can contribute to mental illness.

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