Keywords

Introduction

Islam is currently the world’s second largest religion, with approximately 1.6 billion followers worldwide, and is expected to be nearly equal in number of followers to Christianity by 2050 (Pew Research Center, 2015). While the Asia-Pacific region is expected to remain the home of most of the world’s Muslim population, Muslim immigration to Europe and North America is steadily increasing (Hackett, 2016; Lipka, 2015). The USA admitted 38,901 Muslim refugees in 2016 (note that the USA does not track the religion of other legal immigrants; Connor, 2016), and while Muslims are approximately 1% of the US population at present, they are expected to be 2.1% of the US population by 2050 (Lipka, 2015). Muslim immigration to Western countries is driven by demands for labor, as well as in part by the desires of immigrants for better economic conditions and financial security (Kamali & Abdullah, 2015).

Despite the expected growth of Islam and increase in Muslim immigration to Western nations during the next several decades, important aspects of Muslim acculturation are not well understood (Khawaja, 2016). Acculturation itself is a topic in psychological theory that is hotly debated, with current models suggesting that the characteristics of individual immigrants, the traits of their originating group, and tendencies of the host society all interact in complex ways (Khawaja, 2016). Other recent work suggests that acculturation is not a uniform or “whole cloth” process; positive and negative effects can be observed simultaneously or sequentially, and instances of acculturative processes may be viewed continuously or discretely (Ali, 2008; Al Wekhian, 2016; Khawaja, 2016). Muslim immigrants, especially in the post-9/11 era, experience unique integration and acculturation challenges. Muslims face prejudice and discrimination in Western nations in which they are a minority (Ansari, 2004; Panagopoulos, 2006; Sheridan & Gillett, 2005; Zolberg & Woon, 1999). The effects of discrimination complicate the already difficult process of Muslims acculturating to new societies that they find themselves living in. Given recent events, how are Muslim immigrants affected by these processes? How is the experience of US born Muslims similar or different? What should the behavioral health service provider know about working with Muslims as clients?

The goal of this chapter is to review the literature regarding behavioral health service delivery for Muslim clients (with a focus on psychotherapy services), as well as orient the reader to supplemental knowledge that is intended to increase cultural competency. This will include information about behavioral health needs relevant to Muslim clients. It will also briefly define and review acculturation and the related construct of acculturative stress. In addition, this chapter will examine a key topic relevant to Muslim integration with the West: the issue of Islamic jurisprudence and how it directly relates to acculturation and acculturative stress. Given the potential for misunderstanding regarding the nature of Islamic jurisprudence, the section will emphasize the nuance and diversity of opinion in the Islamic world on this topic. Recommendations for conducting psychotherapy and other behavioral health interventions with Muslim clients will be discussed. Note that because of space considerations, this chapter does not include an introduction to the basic tenets of Islam. The reader with little background on Islam is referred to other literature to establish some familiarity with its basic features as a religion (e.g., Ali, Liu, & Humedian, 2004)

Current Mental Healthcare Needs of Muslim Clients

Robust epidemiological data about the prevalence of mental and behavioral health problems in the US Muslim population is scarce, at best. Common mental health problems encountered in treatment with US Muslims include marital and relationship problems, issues related to religious taboos (drug and alcohol use, sexual activity outside of heterosexual marriage), depression, and anxiety (Arfken & Ahmed, 2016; Rassool, 2015)

Muslim women experience unique needs as a result of gender role expectations within cultures that predominantly endorse Islam. Rules regarding opposite-sex interactions, as well as the general level of patriarchy common in Muslim societies, are two areas where Western trained clinicians may stumble (Ibrahim & Dykeman, 2011). Studies have identified multiple factors that influence Muslim women’s interaction with healthcare providers: (1) the perceived power differential between client and provider, (2) religious proscriptions regarding gender and mixed-gender interactions between non-related persons, and (3) deference to male familial figures when making treatment relevant decisions (Hammoud, White, & Fetters, 2005; Ibrahim & Dykeman, 2011; Simpson & Carter, 2008). For example, handshakes or other forms of physical contact between female Muslim clients and male care providers are discouraged (for more guidance and recommendations, see Hammoud et al., 2005). When domestic violence concerns are salient, providers may benefit from reviewing how Islam and other religions can be misinterpreted in an attempt to justify violence against women (Jayasundara, Nedegaard, Flanagan, Phillips, & Weeks, 2017).

Effects of Acculturative Stress on Muslim Mental Health

Acculturation can be defined as the process of bidirectional change that takes place when two different ethnic and/or cultural groups encounter one another, and change occurs as a result (Bourhis, Moise, Perreault, & Senecal, 1997; Redfield, Linton, & Herskovits, 1936). Acculturation expectations vary for both various ingroup and outgroup populations. For example, it is possible to sort the acculturation expectations of ingroup members into categories such as integrationism, segregationism, and assimilationism (Kunst, Sadeghi, Tahir, Sam, & Thomsen, 2015). Segregationism is the stance that minorities should keep their heritage culture intact, but they should also be isolated from the society at large. Assimilationism expects minority members to embrace the host or national culture while also identifying less with and eventually abandoning their heritage culture. Integrationism argues that minorities can and should adopt the national culture, while also being connected to their heritage culture. Integrationism is the only stance that requires the majority society to change in some way, for accommodating new members. When thinking about minority group members (such as Muslims immigrating to or residing in the West), Berry (1980) suggests that these individuals are trying to balance the desire to maintain affiliation with their heritage culture, while also growing to appreciate the national culture they now live alongside. Recent research supports the notion that acculturation is better understood as a bidirectional process rather than a unidimensional one, with implications for personality, identity development, and other psychosocial factors (Ryder, Alden, & Paulhus, 2000). Successful acculturation is a set of psychological processes that enable integration (Berry, 2001, 2008; but for readers interested in the possible limitations and an expansion of Berry’s ideas; see Ward, 2008)

It is well documented that acculturative stress impacts the well-being of Muslim immigrants to the USA and other Western nations. In the USA, barriers to successful acculturation include cultural and religious differences, differing views on gender, discrimination, the portrayal of Muslims in popular media, and differences in moral and ethical values (Al Wekhian, 2016). Driscoll and Wierzbicki (2012) have found that religiousness, not acculturation, predicts lower levels of depression in Pakistani and Palestinian Muslims in the USA, though acculturation did predict lower interpersonal causes of depression. This suggests that different etiological mechanisms may be at play that differentially interact with acculturation, an area that requires further study. Depression in older Muslim immigrants is partially predicted by identifying with heritage culture as opposed to American culture (Abu-Bader, Tirmazi, & Ross-Sheriff, 2011). Higher levels of acculturative stress predict lower levels of life satisfaction and higher levels of psychological symptoms for Muslims in New Zealand, while interestingly, religious based coping strategies did not affect levels of symptoms (Adam & Ward, 2016). Acculturative stress predicts decreased life satisfaction and greater behavioral problems for young Muslim adults in both New Zealand and the UK; family obligations can increase adaptation but can interact with acculturative stress to predict poorer adaptation as well (Stuart, Ward, & Robinson, 2016). Muslim immigrant adolescents who are younger, more religious, and have spent less time in the USA are more likely to endorse strong identification with their heritage culture, with no corresponding association with the host culture in the opposite direction (Goforth, Oka, Leong, & Denis, 2014). Other research shows a link between perceived discrimination and subclinical paranoia, but not anxiety, with differences across subgroups (Rippy & Newman, 2006).

The presence of hostile attitudes on the part of majority group members seems to predict difficulty acculturating for US Muslim immigrants (Kunst et al., 2015). In addition, how mental health stigma interacts with aspects of Muslim identity is poorly understood, and more research is needed (Ciftci, Jones, & Corrigan, 2012). What we do know is that in part because of stigma, Muslim mental health problems are sometimes expressed somatically or as physical symptoms (Fakhr El-Islam, 2008). In addition, particularly in the USA, the impact of racial discrimination on the mental health of minorities is understood for several racial groups, including African-Americans, Hispanics, Asian-Americans, Jews, and others. However, there is less research that specifically examines the effects of discrimination on Muslims as a religious group (Rippy & Newman, 2006). One recent study with a national sample of Muslims did conclude that experiencing discrimination was predictive of depression but not of substance abuse (Hodge, Zidan, & Husain, 2015).

There is also a need to further understand how the racial or ethnic backgrounds of Muslims (i.e., India, Indonesia, Nigeria, Bosnia, Caucasian, etc.) intersect with other aspects of identity in the context of prejudice and discrimination. For example, Ajrouch and Kusow (2007) found that, in an ethnographic interview study, Lebanese and Somali Muslim immigrants use different strategies in integrating with Western countries. Both groups seek to make their religious identities salient. However, Somali immigrants experience “othering” processes with both their race and religion, while Lebanese immigrants do not experience this about their race. There is additional literature available on the nuances of how Islamic and racial identities intersect and relate to acculturation, which is recommended reading for providers who see a diversity of ethnic identities in their settings (e.g., Archer, 2001; Meer, 2008; Sirin & Fine, 2007). What is clear is that acculturation interacts with a variety of other psychological and sociological processes as a predictor of stress and mental well-being. Behavioral health providers can avoid the pitfalls of confusing cultural, ethnic, and religious identities by being mindful of the intersectionality of Muslim client identities. Indeed, though many Muslim Americans are Arabs, more Arab Americans are Christians than Muslims (Hammoud et al., 2005).

As previous research has shown, acculturation is a key process for any immigrant population moving to a nation with a different culture. Skills for living in the host society, as well as having the freedom to maintain heritage traditions, are directly related to decreased distress among Muslim immigrants (Fassaert et al., 2011). Therefore, it is important to have a clear understanding of the psychological processes at play during acculturation. Muslim immigrants, like others, experience varying degrees of acculturation success. Examining how Muslim immigrants have adapted one important aspect of their culture to Western societies demonstrates the potential for immigrant communities to integrate successfully. For native born Muslims in Western societies, this aspect is still both an important facet of cultural heritage, and a potential source of misunderstanding.

Islamic Jurisprudence

Cultural and religious traditions develop legal systems and legal philosophies, and such a history is also richly present in Islam. Islamic jurisprudence refers to the application of Islam to the study of laws, legal codes, and legal theories. This not only includes the Qur’an itself, but also the history of social and legal customs in the wider Islamic community (Sunnah) as well as the consensus of Islamic legal scholars (Ijma), among other components (Kamāli, 2003).

Stereotypes about the encroachment of Sharia law into US society is linked to pronounced, irrational fear of Muslims (Fallon, 2013). Contrary to stereotypes about Muslims and their desire for Sharia to be the dominant legal system where they live, Muslims around the world vary considerably in their beliefs that Sharia should be codified into their respective nation’s laws; whether Islam is an official state religion seems to be a key variable (Pew Research Center, 2013). Like other religious systems, Islamic law is frequently relevant to medical ethics and decision-making by both Muslim physicians and Muslim patients (Butt, 2012; Hatami, Hatami, & Hatami, 2013; Shapiro, 2013; Varley, 2012; Zainuddin & Mahdy, 2017). It is suggested that behavioral health providers that work in areas allied with medical practice, such as hospital settings or integrated care, review foundational information on Islamic bioethics in order to facilitate better understanding and cultural competency when engaging with Muslim clients, especially in a medical decision-making context (e.g., Chamsi-Pasha & Albar, 2013; Daar & Khitamy, 2001).

Muslim individuals tend to believe that, unless they live in societies in which Islam is the state religion, living in a democracy generally entails living with secular legal systems and view these systems as enablers of religious pluralism, which is ultimately good for everyone (Pew Research Center, 2013). For Muslims, the notion of arbitrating legal disputes in the context of Sharia allows them to retain linkages to their heritage culture even as they seek to integrate successfully into non-Muslim countries. For many Western cultures, the subject can be a touchy one. Korteweg (2008) describes how the issue of Sharia council arbitration prompted a vigorous debate in Ontario, Canada. Korteweg illustrates how notions of agency are embedded within cultures and are directly related to how one would conceptualize Sharia councils as either encroachments on the autonomy of Muslim women, or as culturally relevant aspects of Muslim identities for both men and women. As previously discussed, the degree to which Muslims are able to relate to their heritage culture is directly related to their well-being. When it comes to the various dimensions by which Muslim immigrants successfully interface with host societies, how all the parties deal with the issue of Sharia is directly related to the extent by which Muslims experience prejudice and discrimination, and the extent by which majority group members experience unfounded paranoia and fear (Khan, 2012). Specific to the USA, it appears that fear of Muslims is at least in part due to the political and legislative activities of organizations opposed to a “Sharia takeover” (Uddin & Pantzer, 2011). Thus, it is imperative that any discussion on how acculturation is successful for Muslim immigrants, or how natural born Muslim citizens interact with Western societies generally, includes a discussion of Sharia and the function it serves Muslims in daily life. Understanding these functions is relevant for providing effective behavioral health services.

Bowen (2011) provides a useful analysis of how Muslim communities in France, the U.K., and the USA apply the principles of Islamic jurisprudence within the context of their host societies to the topic of women seeking divorces. Divorce in Islamic law is complicated because men and women have different powers per most schools of Islamic jurisprudence. A man can annul his marriage and release his wife from the obligation to pay a dower, but a woman can either ask her husband to divorce her or ask a judge to dissolve the marriage if her husband has failed to perform his duties (Bowen, 2011). Most Muslims live in areas with modern legal systems that more closely resemble either British common law or French civil law (indeed, civil and common law are the two most widespread legal traditions around the world; Merryman & Pérez-Perdomo, 2007). Civil law resembles the legal system of the USA: ordinances and statutes define with actions are illegal and prescribe penalties for engaging in those acts. Common law relies almost entirely on case precedent and judicial prerogative in resolving legal issues; while judges in civil law systems draw upon case precedent in the context of applying codified law, precedent is the entirety of common law systems (Merryman & Pérez-Perdomo, 2007).

More so than other nations in Europe and the USA, Muslims in the U.K. tend to live in clustered neighborhoods composed almost entirely of other Muslims; such neighborhoods also cluster by nation of origin (Bowen, 2011). English common law also provides more room for legal legitimacy of religious organizations as compared to civil law. Judges in England are willing to defer to the decisions of Sharia councils in England on matters of marriage, so long as the council’s legal process and outcome do not conflict with English precedent (Bowen, 2011). Thus, mediations by Sharia councils in England enjoy a status of legitimacy not seen elsewhere. In the USA as well as France, the situation is quite different. While in England marriage is largely an individualized and contractual matter, the French treat marriage and family as important aspects of public life and society. The structure of French civic life and its legal institutions do not permit religious councils any formal role in resolving matters such as marriage (Bowen, 2011). Imams in France encourage couples to first get married in civil court before having an Islamic marriage, as imams who marry Muslims who are not civilly married are guilty of a crime in the French system (Bowen, 2011). In matters of divorce, imams frequently council women to seek civil divorce and mediation, and often find themselves assuring Muslim women that they are not disrespecting their faith by doing so (Bowen, 2011). In the USA, court systems rely on civil law (as in France), but Sharia councils are still permitted (as in England). As opposed to councils in England, where multiple schools of Islamic jurisprudence exist, only one school is common, and is predominantly endorsed by South Asian Muslims. These councils (often lone imams) can be approved by US courts to grant marriages and deal with dowers as issues of prenuptial agreements, but this varies state to state. American courts are more wary than English ones to refer to religion or religious precedent; as a result, imams in the USA have sought guidance from US judges on how to frame or word dower arrangements such that they resemble contracts recognized in the American legal system (Bowen, 2011). These three different legal realities for Muslim immigrants are arguably reflections of the little discussed school known as “jurisprudence of Muslim minorities” (Kamali & Abdullah, 2015; Kazemipur, 2016). The goal of this school is to ensure that Muslim minorities have a coherent system with which to interpret Islamic law, while also being sensitive to the reality that traditional Islamic jurisprudence may not be compatible with non-Muslim societies. For example, Kamali and Abdullah (2015) state that the jurisprudence of Muslim minorities specifically calls on Muslims to both preserve their religious identities, but also to act in good faith and be responsible citizens of the countries they live in. It suggests a balance between literal interpretations of Sharia, as well as contextual considerations and the overall aspirational goals of the religious life. There is at present a continued debate as to how much comity, or acknowledgement of foreign precedent, US courts should grant to Islamic legal precedent (Fallon, 2013).

The nonpartisan Council on Foreign Relations, a US think tank, provides another interpretation of how Muslims view the relationship between Sharia and secular legal systems in society (Johnson & Sergie, 2014). Specifically, they suggest that Muslims tend to prefer one of three different arrangements: dual legal system (in which Muslims may choose to take family law and financial disputes to Sharia councils), religiously influenced governments (typically where Islam is the official state religion), and complete secular governments (though these are less common). Muslims still tend to prefer democratic forms of government over strong, authoritative systems (Johnson & Sergie, 2014).

The imams and their unique strategies discussed in Bowen (2011) demonstrate a kind of political acculturation, balancing the values of the immigrant group with the values of the broader society. Political acculturation refers to the degree to which immigrants advocate for their ingroup as well as the broader societal interest. Whether immigrant political activity is perceived as valuing ingroup interests and/or valuing societal interests yields the following categories: integration, assimilation, separation, and marginalization (for more information, see Hindriks, Verkuyten, & Coenders, 2015). Positive acculturation outcomes depend in part on the ability of Muslim minorities and majority groups to come to consensus on legal and other issues (Kazemipur, 2016). How do these imams find success and sustain it in these ways? What are the factors that predict such success? These issues suggest promising lines of inquiry for social, cultural, and political psychologists. Conversely, behavioral health providers should orient to how particular clients view the role of Islamic jurisprudence in their daily lives. Providers should focus on asking and understanding the perspective of the client that they see, as well as the practices of the family system that the client is associated with. Muslim individuals and their families vary the degree to which they incorporate Islamic judicial practice into their culture. Identifying the general stance that the family system takes on matters related to Sharia and Islamic law may be useful for anticipating or resolving religious conflicts. For more information on working with Muslim couple and family dynamics, see Springer, Abbott, and Reisbig (2009).

Taking a Broader Social Perspective: Contact Theory and Intergroup Contact

As has been discussed thus far, Muslim residents in the USA face prejudice and discrimination. Behavioral health providers do not see individual Muslim clients separate from their context: clients seek services as members of families and communities. These communities, in non-Muslim majority societies, face challenges at the group level of analysis related to negative intergroup relations. In order to relate effectively to clients from these backgrounds, providers are likely to benefit from a broad perspective that incorporates these group level processes into their conceptualization of Muslim clients and the problems that they report. Indeed, such a multi-level view comports with the actual considerations some Muslim individuals weigh when deciding whether or not to seek services (e.g., Alhomaizi et al., 2017).

It is necessary to frame a discussion around the social psychology of Muslim acculturation and intergroup relations in the context of a suitable theory, one with strong theoretical and empirical work behind it, and that can provide concrete suggestions to stakeholders. Intergroup contact theory (or contact theory) is one of the most widely investigated theories in social psychology and has its basis in natural observations of intergroup change (Pettigrew, Tropp, Wagner, & Christ, 2011). Contact theory was first proposed by Allport (1954), who suggested that contact between outgroup and ingroup members can improve intergroup relations, including reducing the impact of prejudice on the outgroup. Allport (1954) argued that four conditions are key for intergroup contact to have positive effects: (1) contact should occur between individuals of equal status, (2) groups should have shared goals, (3) attainment of those goals should involve cooperation between groups, and (4) sustained cooperation requires the involvement of institutions and authorities. Pettigrew (1998) suggests a fifth condition that the contact in question allows the opportunity for friendships to develop between individuals. In an important meta-analysis that examined findings from 515 studies, Pettigrew and Tropp (2006) concluded that intergroup contact generally reduces intergroup prejudice, and that more rigorously controlled studies show greater treatment effects, while also suggesting that more research needs to be conducted that shows what factors might prevent the reduction of prejudice after intergroup contact.

Hutchison and Rosenthal (2010) examined the role that anxiety may play as a mediator between Muslim-majority intergroup contact and attitudes, perceived group variability and perceived intentions. They note that perceived group variability (the degree to which one perceives an outgroup as homogenous versus having variability between members), while related to decreased prejudice, does not fully mediate it. In a pair of cross-sectional studies, Hutchison and Rosenthal (2010) showed that anxiety about intergroup contact mediates the relationship between intergroup contact and attitudes towards Muslims. While these studies cannot demonstrate causation and were conducted with convenience samples of White majority university students, they represent an important step in characterizing the causal pathway by which intergroup contact functions to reduce prejudice. The mediating effects of anxiety reduction remained even when controlling for the duration, quantity, and quality of the intergroup contact as reported by the participants. However, what is not clear is whether this effect is related to, or better explained by, symbolic threat. A review by Hodson (2011) supports the notion that anxiety reduction is a key process for positive intergroup contact, especially for outgroup intolerant members of a majority group.

Gaddis and Ghoshal (2015) conducted a study in which they mass mailed applications for rental units to postings in several major US cities. The applications included Arab female names, as well as indications of gainful employment and college degrees. Gaddis and Ghoshal (2015) found that greater discrimination occurred with listings that were geographically closer to mosques. Gaddis and Ghoshal’s results orient the scientific community to consider a potential paradox. Specifically, there is evidence that intergroup interactions can in fact produce negative effects of intergroup bias (i.e., MacInnis & Page-Gould, 2015). However, there is a lack of consensus about how robust these effects are, and at least one paper suggests that they are mediated by social ties (Stolle, Soroka, & Johnson, 2008).

Contact theory has been successful in identifying how some factors (especially positive intergroup contact) lead to reduced prejudice from ingroups towards outgroups. However, more research needs to be conducted to show how contact theory applies to acculturation in general, and to intergroup contact between Muslims and Western cultures specifically. What contact theory does presently support is the importance of the healthcare provider as a point of contact between the two. Muslims report ambivalence and uncertainty about engaging with behavioral healthcare providers as well as healthcare providers in general. How providers engage with Muslim clients, and the degree to which providers strive to provide culturally competent care, has an impact not only on the individual client, but how the client’s community perceives the helping professions writ large.

Intervening with Muslim Clients

Research on US Muslim and Muslim immigrant populations points the way towards several potentially useful sets of guidelines for engaging Muslim clients in behavioral health. However, it is important to emphasize that recommendations presented in this chapter do not constitute a “cook book” for providing effective services. The literature to support developing step-by-step instructions on providing interventions in a culturally competent and effective manner is simply not there yet (Beshai, Clark, & Dobson, 2013). For example, a recent meta-analytic review found that faith-adapted cognitive-behavioral interventions (F-CBT), or CBT interventions that explicitly incorporate the spiritual or religious perspective of the client into therapy, found that while F-CBT showed significant benefits, methodological concerns of the study sample limit the ability to draw any firm conclusions (Anderson et al., 2015). Another review found that even literature focused only on depression sometimes contained contradictory advice or based claims on poor or no evidence (Walpole, McMillan, House, Cottrell, & Mir, 2013). However, there are generally effective stances and attitudes that are likely to be useful in working with this population, such as the interview questions suggested by Rassool (2015).

Abu Raiya and Pargament (2010) summarize a wide literature about Muslim mental health and the role that Islam plays in the well-being of Muslim individuals. Drawing on empirical research, they make five suggestions for psychotherapy providers: (1) clinicians should inquire directly about the role that religion plays in the client’s life, (2) clinicians should inquire the degree to which the client identifies as a practicing Muslim, and have basic background knowledge of Islamic beliefs and practices, (3) clinicians should help Muslim clients orient towards positive religious coping skills, (4) clinicians should assess, identify, and normalize religious struggles, referring to an imam when appropriate, and (5) clinicians should disseminate information about psychotherapy and psychopathology to Islamic communities. See Ibrahim and Dykeman (2011) for discussion of and suggestions for conducting cultural assessment with Muslim clients, such as framework for assessment as well as some measurement suggestions.

Beshai et al. (2013) provide an overview of the similarities and differences between the philosophical worldviews presented in both cognitive-behavioral therapy (CBT) and Islam. They note that for some followers of Islam, mental distress and symptoms are viewed as tests from Allah, which may be alleviated by prayer and adherence to doctrine through personal conduct. Other authors suggest that CBT may in fact be quite compatible with Muslim clients from conservative countries and cultural traditions. This may be because “basic CBT concepts are in alignment with Islamic beliefs…CBT is suitable for the conservative cultural constructs of the populations, where patients initially attend therapy with an apprehension [of self-disclosure]” (Algahtani, Buraik, & Ad-Dab’bagh, 2017, p. 114). The same authors also note that CBT provides a structure that is useful for Muslim clients to both present their concerns and safely build rapport.

Given the documented benefits of religious coping for Muslim clients, behavioral activation (BA) may represent an adaptable intervention that can be tailored to meet client’s needs (for more information about BA itself, see Kanter, Manos, et al., 2010). BA is an efficacious treatment for depression and has previously been shown to be amenable to cultural adaptation (Kanter, Santiago-Rivera, Rusch, Busch, & West, 2010; Kanter et al., 2015). In a mixed-method study, Mir et al. (2015) developed and evaluated a version of BA for Muslim clients in an open trial. In discussions with community and professional informants, the authors found that BA was not only a good fit for Muslim clients in terms of the orienting philosophy (citing Islamic values that promote self-activation and an active stance), but also because BA itself is a highly customizable intervention that is relatively easy to adapt for any given client. The open trial found that a majority of participants reported positive outcomes.

Individuals who practice Islam and who have cultural values derived from Muslim countries place value on the involvement of their social community and their imam in their recovery from mental and physical illness (Ali, 2016; Tobah, 2017). Behavioral health providers should not be surprised if a Muslim client wishes to involve family members or their imam in their treatment. Such involvement of the client’s social milieu is typical; the limited literature on Muslim’s seeking out pastoral counseling suggests that Muslims routinely consider it an option worth pursuing, and even sometimes see secular mental health providers and pastoral counselors concurrently (Ali, 2016; Ali, Milstein, & Marzuk, 2005).

Conclusion

Best practices for providing effective behavioral health services to US born Muslims and Muslim immigrants are still not fully understood. There is a continued need for research and practice evaluation in order to establish empirically informed guidelines (Anderson et al., 2015; Beshai, Clark, & Dobson, 2013; Walpole et al., 2013). Muslim immigration is expected to continue, and geopolitical conflicts that are ongoing in the Middle East and South Asia are likely to contribute to unique difficulties for the acculturation of Muslim immigrants. Given that Muslims have shown the ability to embody complex identities, as well as acculturate successfully to different societies around the world, promoting successful acculturation should be a priority for the behavioral health practitioner. Acculturation, prejudice, and discrimination continue to have consequences for Muslims and as a result, societies at large. Readers who anticipate working with Muslim clients would do well to stay abreast of the latest scholarly findings that could inform effective practice (the Journal of Muslim Mental Health is especially recommended for hopefully clear reasons).

It is hoped that this chapter has provided useful suggestions and areas for further reading for the clinician. Understanding context, both historically and presently situated, when working with Muslim clients is likely key for positive outcomes.