PROTECTIVE FACTORS IN MUSLIM WOMEN'S ...

PROTECTIVE FACTORS IN MUSLIM WOMEN’S MENTAL HEALTH IN THE SAN FRANCISCO BAY AREA

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A University Thesis Presented to the Faculty of California State University, East Bay

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For Partial Fulfillment For the Requirements of the Degree Master of Social Work

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By Sarah Huxtable Mohr June, 2017

Copyright © 2017 by Sarah Mohr

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ABSTRACT Not enough is known about how religion and spirituality (R/S) operate as protective factors for Muslim women's mental health. In a mixed methods study, 20 Muslim women, including community members and mental health clinicians, participated in focus groups and individual interviews, respectively, to explore how R/S supported Muslim women’s social support, self-esteem, and emotional well-being in the San Francisco Bay Area. Through the qualitative research, the researcher found that, consistent with other studies, being Muslim had a direct positive effect on self-esteem as defined by participants and emotional health as measured in the study by happiness, life satisfaction and meaning and purpose. This positive impact was found in many areas of life, including the ethical and moral values R/S gave women, the emphasis on learning and education, the support of family members, internalized self-worth based on a loving Creator and the meaning this gives to life. Women who participated had a more mixed view of the social support that R/S give them, including mixed feelings about the local community and social pressures. Quantitative results showed no correlation between religiosity, life satisfaction, or demographic data. Knowledge of protective factors for health among Muslim women may contribute to improving health treatment strategies and decreasing culturally based stigma against this growing minority population. Keywords: protective factors, Muslim women, San Francisco Bay Area, selfesteem, emotional well-being, social support

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PROTECTIVE FACTORS IN MUSLIM WOMEN'S MENTAL HEALTH IN THE SAN FRANCISCO BAY AREA

By Sarah Huxtable Mohr

Approved:

Date:

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J?f{tp-= o2(' :2»/1Dr. Carl Stempel

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ACKNOWLEDGEMENTS My heartfelt gratitude to the women who participated in this study. Without their generosity, none of this would have been possible. I would like to acknowledge and thank Dr. Rose Wong, my thesis committee chair, advisor, and professor, for her help in making this come to fruition as well as my thesis committee members, Dr. Holly Vugia and Dr. Carl Stempel. Thanks to Dr. Jenny O from the Center for Student Research for her guidance analyzing the quantitative data. The Center for Student Research also provided a travel grant to the 9th Annual Muslim Mental Health Conference in East Lansing, Michigan, which aided in the development of some of the ideas in the Discussion. Additionally, I would like to acknowledge my family for their patience and support, especially my son. Finally, my gratitude to God for health, both mental and physical, and mercy.

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TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii ACKNOWLEDGEMENTS .................................................................................................v CHAPTER ONE: INTRODUCTION ..................................................................................1 Statement of Problem ...............................................................................................1 CHAPTER TWO: LITERATURE REVIEW ......................................................................6 Research on PFs .......................................................................................................6 R/S as a PF for Mental Health .................................................................................8 R/S as a PF among Muslim Women ........................................................................9 Social Support ..............................................................................................9 Muslim women and social support. ............................................... 11 Negative impact of social support..................................................12 Self-esteem .................................................................................................13 Muslim women and self-esteem ....................................................14 Emotional Health .......................................................................................16 Muslim women and emotional health ............................................16 Muslim women and happiness ...........................................16 Muslim women and life satisfaction ..................................17 Muslim women and meaning and purpose ........................18 Conclusion .........................................................................................................................18 CHAPTER THREE: METHODOLOGY ..........................................................................20 Research Question and Hypothesis ........................................................................20

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Methods..................................................................................................................20 Design ........................................................................................................20 Study Setting ..............................................................................................21 Sample........................................................................................................21 Instruments .................................................................................................22 The Duke University Religion Index .............................................22 The Satisfaction with Life Scale ....................................................23 Interviews with Mental Health Professionals ............................................24 Focus Groups with Community Women ....................................................25 Data Collection Procedure .........................................................................25 Data Analysis .............................................................................................26 CHAPTER FOUR: RESULTS...........................................................................................27 Sample Characteristics ...........................................................................................27 Clinicians .......................................................................................27 Focus group participants ................................................................27 Quantitative Findings ............................................................................................28 Correlation Analysis.......................................................................28 Qualitative Findings ...............................................................................................29 Social Support ............................................................................................30 Sense of Belonging ........................................................................30 Support from moral values.............................................................31 Learning as social support .............................................................32

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Positive peer support ......................................................................32 Family support: R/S as guidance and hindrance ............................33 Problems with social support in the community ............................35 Social justice and social support ....................................................37 Hijab and social justice ..................................................................38 Hijab and social support.................................................................39 Self-esteem .................................................................................................40 The essential value of the human being .........................................40 Pride in being Muslim ....................................................................41 Strong Values .................................................................................42 Care-giving and service .................................................................42 Education and learning ..................................................................44 Stories ............................................................................................44 Prayer .............................................................................................45 Holistic view of Islam ....................................................................45 Negative impact of R/S on self-esteem ..........................................45 Emotional health ........................................................................................46 Prayer .............................................................................................46 Gratitude ........................................................................................47 Patience in adversity ......................................................................48 Social justice and meaning and purpose ........................................49 Belief in heaven .............................................................................49

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Other themes ..............................................................................................50 Islamophobia ..................................................................................50 Mental health among Muslims in the Bay Area.............................50 CHAPTER FIVE: DISCUSSION ......................................................................................53 Quantitative Findings .............................................................................................53 Qualitative Findings ...............................................................................................54 Social Support ............................................................................................54 Self-Esteem ................................................................................................56 Emotional Health .......................................................................................57 Conclusion .............................................................................................................58 Implications for Developing Spiritually Competent Services ...................58 Implications for Promoting Respect and Inclusion of Muslim Culture .....60 Research on Muslims and Social Advocacy ..............................................61 Limitations .................................................................................................62 Future Research .........................................................................................64 REFERENCES ..................................................................................................................65 APPENDIX A ....................................................................................................................80 APPENDIX B ....................................................................................................................81

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CHAPTER ONE: INTRODUCTION Statement of Problem The study of protective factors (PFs) is useful to developing strength-based solutions to the mental health problems faced by the diverse racial and ethnic communities in the U.S. (Koenig & Shohaib, 2014; Ungar, 2011; Ungar, 2013). The study of PFs receives little attention compared to the study of risk factors generally (Patel & Goodman, 2007), yet knowledge of religion and spirituality (R/S) as a PF can contribute to a better understanding on the strengths of diverse cultural communities and their mental health (Abdullah, 2015; Andermann, 2010; Graham, Bradshaw, & Trew, 2009; Graham, Bradshaw & Trew, 2010; Hodge, Zidan, & Husain, 2016a;) and more research on PFs is needed (Luthar, Cicchetti, & Beckman, 2000; Patel & Goodman, 2007). One community in need of such strength-based strategies is the Muslim community (Abdullah, 2015; Bjorck & Maslim, 2011; Graham et al., 2009; Graham et al., 2010; Hodge, Zidan, & Husain, 2015; Hodge et al., 2016a). This mixed methods study explored three PFs that have been linked to R/S, social support, self-esteem, and emotional health, in Muslim women in the San Francisco Bay Area in order to contribute to the development of strength-based mental health interventions for the Muslim community. What little data that is available indicates that the prevalence of mental health problems among Muslims in the U.S is much lower than in the general population (Basit & Hamid, 2010). However, the mental health needs of the Muslim population in the U.S. are viewed as multiplying rapidly (Amer & Bagasra, 2013; Basit & Hamid, 2010; Graham et al., 2009). One reason for the growing need for mental health services among

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Muslims is that Islamophobia and anti-Muslim sentiments are at an all-time high in the U.S. Anti-Muslim hate crimes rose significantly after the September 11th attacks in 2001 as did discrimination against Muslims generally (Amer & Bagasra, 2013; Disha, Cavendish & King, 2011; Epstein, 2011). Additionally, Islam is the fastest growing religion in the U.S. The Pew Research Center estimates that in 2015 roughly 3.3 million Muslims resided in the U.S., which is about 1% of the population (Pew, 2017). Islam is expected to be the second largest religion by 2050 (Pew, 2017). Therefore, the sheer number of Muslims in the population who are at risk is higher (Hodge et al., 2016a). With these considerations, there is an increasing and urgent need for an understanding of how to provide culturally competent mental health and social services to Muslims (Amer & Bagasra, 2013; Graham et al., 2009; Hodge et al., 2016a), an ethical duty for social workers (NASW, 2016) and health professionals generally (AAMC, 2005; APA, 2002). To develop culturally sensitive interventions for Muslim Americans, the role of R/S in mental health is a central consideration (Hodge et al., 2016a; Larson & Larson, 2003; Vieten et al., 2013). In general, the potential for R/S to be used as a tool in psychiatric and mental health healing has not been realized (Hill et al., 2000; Larson & Larson, 2003; Oxhandler & Pargament, 2014; Vieten, et. al., 2013), although progress is being made. As recently as 2013, the American Psychiatric Association published preliminary guidelines for competence in using R/S as a tool in psychological healing (Vieten, et. al, 2013). Also, psychiatric patients cite the importance of R/S in their mental health but in spite of this, R/S is rarely incorporated into psychiatric treatment or mental health interventions (Larson & Larson, 2003).

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The slow development of the use of R/S in mental health intervention has been attributed to Sigmund Freud’s legacy (Koenig & Larson, 2001; Plante, Miller, & Sperry, 2014). Freud was averse to religion and dismissed religion as an infantile, neurotic dependence on an illusory father figure, an infantile fantasy, and a wish-fulfillment (Freud, 1961; Koenig & Larson, 2001; Plante et al., 2014). Freud set the stage for the conflict between R/S and mental health. Other prominent figures in modern psychology such as Albert Ellis, the founder of cognitive behavioral therapy, also held negative views of religion (Koenig & Larson, 2001; Plante et al., 2014). In the context of this legacy of hostility between R/S and mental health, social work schools have little curriculum focused on R/S and most social workers do not know how to incorporate R/S into their work with clients (Oxhandler & Pargament, 2014). Many social workers have recognized this deficiency at this point. Social workers began to reintroduce the topic after 30 years of omission from social work literature in the late 1990s (Sheridan & Amoto-von Hemert, 1999) and have also espoused conceptualizing clients within a biopsychosocial-spiritual framework rather than merely the more traditional biopsychosocial framework (Graybeal, 2001). In spite of a modern Western lack of connection between R/S and mental health, historically there have been close ties in the Islamic world between R/S and health, including mental health for the entire history of Islam (Koenig & Shohaib, 2014). In fact, in the Quran, God states that the Quran has been sent to humanity as a healing (Quran 17:82, from Koenig & Shohaib, 2014). This belief corresponds with the development of medicine and concepts of psychosocial health by Islamic scholar and physicians, which

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predates the development of medical knowledge in Europe by roughly a thousand years, longer if developments that predate Islam in the Islamic world are included (Awaad & Ali, 2015; Koenig & Shohaib, 2014). The first psychiatric hospitals were built in the Islamic world as early as the 8th century (Wael, 2008). Islamic beliefs in psychology were quite advanced in a time when in Europe psychiatric hospitals were not even considered due to fear of the mentally ill being possessed by demons (Wael, 2008). Physicians such as Ahmed ibn Sahl al-Balkhi and Muhamed ibn Zakariya Razi were the first to speak of psychotherapy, and describe depression, obsessive-compulsive disorder, phobias and treatments for mental illness such as psychosis and neurosis, in the late 9th and early 10th centuries. (Awaad & Ali, 2015; Awaad & Ali, 2016; Wael, 2008). Al-Balkhi even suggested an approach that is basically the same as modern day cognitive behavioral therapy (Awaad & Ali, 2016). There is a natural connection between Islam and mental health, and Muslims’ religious beliefs and spiritual practices have long served as a way to improve mental health, and are PFs for health in general (Awaad & Ali, 2015). With these historical considerations, for Muslims, the connection between R/S, mental health, and social services is necessary and natural (Abdullah, 2015). Higher degrees of R/S, as mentioned above, have been linked to better health outcomes and shown to be a PF in numerous studies (Dolan, Peasgood, & White, 2008; Hodge et al., 2016a; Koenig & Larson, 2001; Koenig & Shohaib, 2014; Larson & Larson, 2003). In spite of this, little is known about the protective effect of Islam on women generally, and the specific mechanisms of how R/S functions as a PF for Muslim woman (Bjorck & Maslim, 2011; Hodge, Zidan, Husain, & Hong, 2015).

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Understanding how R/S are a PF specifically for Muslim women is important given the issues of sexism, racism, post-colonialism, U.S. imperialism, the War on Terror, and other issues that have depicted Islam and Muslim’s R/S as a liability, particularly for Muslim women (Haddad, Smith, & Moore, 2006). The representation of Muslim women by outsiders as being in need of liberation from their religion is well-documented and pervasive in both historical and contemporary sources (Ebrahimji & Suratwala, 2011; Haddad et al., 2006; Moghissi, 1999; Sayeed, 2002; Wadud, 2006). Yet when speaking for themselves, Muslim women cite their religion as a source of support, self-esteem, happiness, and overall well-being (Ebrahimji & Suratwala, 2011). The general lack of support, stereotyping and discrimination that Muslim women experience in their encounters with social services makes strength-based understandings of Muslim women’s R/S critical (Abdullah, 2015; Haddad et al., 2006).

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CHAPTER TWO: LITERATURE REVIEW Although the literature is sparse, religion and spirituality (R/S) have been found to be a protective factor (PF) for Muslim women in an array of studies and sources. This literature review will synthesize the literature on R/S as a PF, through its impact on social support, self-esteem, and emotional health generally. For each of these areas this literature review will examine how these factors are affected by cultural norms, beliefs, and values among Muslims, and the research on these variables among Muslim women, specifically. Research on PFs Positive psychology, a movement that has developed over the last 30 years, is based on a positive view of the human person. According to this view, psychology should not study only the pathologies, weaknesses and problems of the human being to solve human challenges, but the strengths, assets, adaptations, and PFs that make people thrive (Luthar et al., 2000; Seligman, & Csikszentmihalyi, 2000). The current study is motivated by a positive psychology approach, given that it aims to reveal how Muslim women’s mental health benefits from R/S. One of the motivators behind this research is that it reveals more about the factors we are already familiar with that protect and promote mental health, while simultaneously informing us about factors that we have not considered as fully (Luthar et al., 2000; Patel & Goodman, 2007). Research on PFs often emphasizes quantitative data, focusing on establishing the connection between PFs and good mental health outcomes. However, the study of PFs needs to include not just the identification of PFs per se but also an explanation of how these factors function (Patel &

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Goodman, 2007). PFs are affected by culture, ethnicity, age, and other factors, and it is important to develop culturally sensitive understandings of PFs (Abdullah, 2015; Andermann, 2010; Grothaus, McAullife, & Craigen, 2012; Luthar et al., 2000; Patel & Goodman, 2007; Ungar, 2011; Ungar, 2013) and to be conscious of the social context contributing to the specific adaptation of individuals under stress (Ungar, 2013). There is some research on PFs that has focused on gender as a variable, and there is increasing evidence that gender, like culture, plays a role in determining and defining PFs (Andermann, 2010). Hartman et al. (2009) showed that while PFs are equally important for males and females, boys and girls rely on different individual PFs (p. 249). They focused on the effects of PFs on youth delinquency and found that self-esteem had a greater protective effect for females than males (Hartman et al., 2009). Khamis (2014) found that greater income was more likely to lower psychological distress for men while higher levels of education predicted less psychological distress for women. Billing and Moos (1982) identified family support as more important for women for functioning while work support was found to be more important for men. Other studies, including one in Pakistan (Khan, Watson, Naqvi, Jahan, & Chen, 2015), also found variations in PFs that were based on gender, such as greater spirituality among women and thus a greater positive effect. There is also some evidence that social support affects women and men differently (Shumaker & Hill, 1991) and that happiness, mental health, and religiosity have gender based differences in some populations (Abdel-Khalek, 2006).

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R/S as a PF for Mental Health R/S have been cited as one of the PFs that increases mental health (Dolan, et al., 2008). The dynamic relationship between R/S is multidimensional, and religion and spirituality have complementary and intertwining definitions (Hill et al., 2000; Hodge et al., 2016a; Seybold & Hill, 2001). Religion can be defined as the organized, external and concrete manifestations of worship of God, Higher Power, or the transcendent (Hodge et al., 2016a; Seybold & Hill, 2001), and observance of organized, traditional, world religions, and encouragement to conform to certain patterns of behavior (Seybold & Hill, 2001). Spirituality is more often defined by internal and experiential elements of connection to God, Higher Power, or the transcendent (Hodge et al., 2016a; Seybold & Hill, 2001) or the sacred (George, Larson, Koenig, & McCullough, 2000). Studies on R/S have used a wide array of measures, but there is no one measure that has been standardized to test for religiosity or spirituality (George et al., 2000; Hill et al., 2000; Hodge et al., 2016a; Seybold & Hill, 2001). There is some ambiguity then whether or not R/S have a positive effect on mental health, in spite of ample evidence supporting the claim that R/S have positive health benefits and the fact that the claim is made by many (Koenig & Shohaib, 2014). With this caveat in mind, R/S have been widely linked to positive mental health outcomes, and overall wellness (Dolan et al., 2008; Hodge et al., 2016b). R/S have been linked to lower rates of depression, lower rates of suicide, and lower rates of alcohol and drug abuse (Koenig & Larson, 2001; Larson & Larson, 2003). R/S have also been found to contribute to hope, optimism, purpose and meaning, resulting in less fear and anxiety

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(Koenig & Larson, 2001) and psychological adjustment, particularly among women (Crawford, Handal, & Wiener, 1989). The connection between R/S and greater mental health among women is well documented (Dailey & Stewart, 2007; Hodge, Moser, & Shafer, 2013). In a study on the protective effect of spirituality on African American women, increased spirituality was found to negatively correlate with depression, anxiety and health (Dailey & Stewart, 2007). R/S also have been shown to prevent alcohol and drug uses among adolescent females/young adults (Haber, Grant, Jacob, Koenig, & Heath, 2012) as well as among sexual minority women and heterosexual women (Drabble, Trocki, & Klinger, 2016). R/S as a PF among Muslim Women Learning how the connection between R/S and mental health functions, and how it can be used to improve mental health among Muslims and the delivery of services to Muslims is a central consideration for working with Muslim clients (Al-Krenawi & Graham, 1999). Three of the factors that the literature and anecdotal evidence have suggested as important for understanding how R/S influences mental health are social support, self-esteem, and emotional health. Social Support Like the study of R/S, the study of social support is marked by poor methodological rigor due to the numerous definitions that have been applied and lack of consensus on the construct of social support (Smolak et al., 2013). For instance, one definition is based on a concept of social capital, with social support being defined as family support and community support together (McPherson et al., 2014). In another

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definition, a structural component of social support was concerned with supportive social connections while a functional component was concerned with resources made available to the individual (Shumaker & Hill, 1991). In a third definition, social support was defined as a combination of emotional support, instrumental support, and social interaction (Hovey et al., 2014). Due to the variety and vagueness of definitions of social support, findings on social support have been viewed as having weak validity (Shumaker & Hill, 1991). The current study, given its exploratory emphasis, employed a broad, topographical definition of social support as a combination of peer, community, and family support. A variety of well-being constructs have shown the centrality of social support for understanding wellness and mental health. Social support is one of the strongest predictors of life satisfaction and social well-being (SWB) (Diener, 2012), with SWB being defined as a combination of life satisfaction, presence of positive affect and absence of negative affect (Joshanloo & Afshari, 2011). The contribution of social support to improved mental and physical health outcomes has been established for over 30 years (Cohen & Schneiderman, 1988; Koenig & Larson, 2001; Shumaker et al., 1991). However, the mechanism through which social support improves health and mental health outcomes is less well known. Hypothetically, social support mediates wellness by providing pressure on individuals to engage in healthy behaviors, increasing the availability of resources, buffering stressful life events, motivating people to maintain their well-being, and preventing emotional disorder (Koenig & Larson, 2001; Cohen & Schneiderman, 1988). Social support, however, can also contribute to negative health

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outcomes, when the individual’s supportive network promotes unhealthy behaviors (Cohen & Schneiderman, 1988) or when one is a caregiver facing increased stress and responsibilities (Shumaker et al., 1991). The linkage of social support and R/S is also well established. Essentially, R/S contribute to social support (Ellison, Boardman, Williams, & Jackson, 2001; Hovey et al., 2014; Koenig & Larson, 2001), which in turn contributes to diverse outcomes such as decreases in depression symptoms (Commerford & Reznikoff, 1996), improved health outcomes (Al Khandari, 2011), and better coping with mental illness (Smolak et al., 2013). Involvement in religious activities has been positively related to SWB as well (Dolan et al., 2008; George et al., 2000). Muslim women and social support. Because the culture of most Muslim countries is collectivistic, defined as cultures that give the group priority over the individual (Oxford Online Dictionary, 2017), researchers have posited that social support is a major factor in life satisfaction for Muslims (Diener et al., 1995). This has been born out in some research and continues to be debated in relationship to other factors determining mental health and well-being such as self-esteem and happiness. Diener et al. (1995) suggest that family support may be an area which is particularly crucial for collectivist cultures, given that the family is the most important grouping in most societies. Families often play a significant role in the lives of Muslim clients, and it is important that clinicians are aware of this fact in their treatment of Muslim clients (Ahmed & Reddy, 2007; Bjorck & Maslim, 2011). Muslim women often see the support for women as wives and mothers as well as the encouragement of education among

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women as supporting their social selves in healthy ways (Bjorck & Maslim, 2011; Haddad et al., 2006). The Quran emphasizes the importance of family, especially parents (Quran 4:36 & 17:23-24). The Quran also emphasizes the community of Muslims, the importance of the believers being friends with each other, and makes congregational prayer mandatory. As a result, social support is important to Muslims both in the U.S. and in Muslim countries. Many studies have highlighted the importance of social support to Muslims both in the U.S. and internationally. In their comprehensive review of quantitative studies of social support as a function of R/S among Muslims, Koenig and Shohaib (2014) cite seven studies done on the correlation between R/S among Muslims and their level of perceived or actual social support, with six finding positive correlation between the two variables (p. 200-201) and one study finding no association. In a study of women recruited from a North American Muslim women’s magazine, Bjorck and Maslim (2011) found a positive correlation between R/S and social support. In a large study of 1472 adults over the age of 60 years old in Kuwait, high religiosity predicted a high level of social support (Al-Khandari, 2011). Negative impact of social support. While most studies demonstrate the positive influences of R/S on social support among Muslim women, negative influences have also been found. Koenig & Larson (2001) comment that religion does have the potential to negatively impact social support. Through increased guilt, fear and shame, religion can be detrimental to mental health. Additionally, it can cause low-self-esteem when individuals are unable to meet high religious standards for behavior (Koenig & Larson, 2001).

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Religion can also produce authoritarianism, dogmatism, rigidity and dependency (Seybold & Hill, 2001). There is also support in the literature for negative social support such as marital conflict, or depression in a spouse (Ahn, Kim, Zhang, Ory, & Smith, 2017). However, keeping this in mind, religion, as a whole, in the majority of cases produces positive effects on social support and functioning (Koenig & Larson, 2001; Seybold & Hill, 2001) and this may be the main cause for R/S’s protective effect on mental health (Sherkat & Reed, 1992; Hovey et al., 2014). Mental health clinicians reflect these presuppositions about the negative effects of R/S on Muslim women in the area of social support. Kakoti (2012) discusses several instances of cultural incompetence with Arab American women and the family, including encouraging the expression of anger in ways that are culturally inappropriate and damaging to supportive family relationships, as well as the danger of Western health professionals focusing on marital relationships and not the client’s primary presenting complaints due to stereotypes of Arab culture (p. 64). These kinds of stereotypes are pervasive not just among Arab American women but among many Muslim women from a variety of backgrounds. Again, cultural competence is imperative for understanding Muslim clients, especially for understanding their strengths (Kakoti, 2012). Self-Esteem Self-esteem has been positively correlated with mental health. For example, selfesteem is a good predictor of life satisfaction in measures of SWB (Diener et al., 1995). R/S have also been linked to self-esteem and feelings of mastery (Ellison et al., 2001). However, in collectivist cultures, self-esteem tends to be less predictive of mental health

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than in individualistic cultures (Diener et al., 1995). Self-esteem has also been linked to R/S, and studies have shown that R/S increase self-esteem (Sherkat & Reed, 1992). Muslim women and self-esteem. Textually, Islam validates the existential and ontological value of women in relationship to men and in relationship to God (Barlas, 2002; Haddad et al., 2006; Mohr, 2010; Wadud, 1999; Wadud, 2006). In the work of women writing on Islam, there is a focus on redemptive readings of the Quran that support the rights of women based on women’s creation in conjunction with men as opposed to creation stories where women are made from men (Barlas, 2002; Haddad et al., 2006; Mohr, 2010; Wadud, 1999). As a result, many Muslim women view Islam as protective of their sense of self-worth. Additionally, the Islamic concept of fitra, or the fundamentally good original nature of the self, contributes to the positive self-concept of many Muslims (Abdullah, 2015; Joshanloo & Daemi, 2015). Other concepts such as the equal designation of men and women as trustees of the earth, or khalifah (Wadud, 2006), and the concept that the value of all people, regardless of gender, race, or social status, is based on their piety, or taqwa (Wadud, 1999), contribute to the positive view of women both in relationship to men and also ontologically in relationship to God. Many Muslim women also have strongly held beliefs that the early practice of Islam gave women a great deal of honor and respect (Mernissi, 1987). Koenig and Shohaib (2014), in their review of 15 studies of Muslims found that 11 studies reported significant positive relationships between self-esteem and religiosity (p. 181). In two of the studies that did not find a positive relationship between R/S and self-esteem, there was a connection between negative self-esteem and perceived

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discrimination based on R/S (p. 181). Self-esteem has also been correlated with greater religiosity, especially in the face of discrimination (Ghaffari & Çiftçi, 2010). Joshanloo and Afshari (2011), who has studied happiness in a number of large transnational studies, including over 14 different countries, found that among Muslim women in Iran selfesteem positively correlated with life satisfaction. In another study, Joshanloo and Daemi (2015) found that in Iranian undergraduates, self-esteem mediated the relationship between R/S and well-being. In a study of Kuwaiti and American Muslim undergraduates, religiosity was correlated with optimism, self-esteem, and self-rating of mental health in the Kuwaiti sample, and only with mental health and self-esteem in the American sample (Abdel-Khalek & Lester, 2013). Abdel Khalek (2011), in a study of Muslim Kuwaiti adolescents, found a positive correlation between religiosity, selfesteem, and SWB, while a negative association was found between religiosity and anxiety (Abdel Khalek, 2011). Often, Muslim women relate their self-esteem to their wearing of the head scarf, also called the veil or hijab. Many people outside of Islam view the dress of Muslim women, particularly the hijab, as oppressive and a symbol of Muslim women’s domination by and subordination to a patriarchal system (Haddad et al., 2006; Hyder, Parrington, & Husain, 2015; Kakoti, 2012; Yaqoob, 2008). Muslim women who wear the hijab often see it as a sign of empowerment and protection, taking the focus away from their bodies and onto their character, behavior, and speech (Ahmed & Reddy, 2007; Haddad et al., 2006; Hyder et al., 2015; Mussap, 2009; Odems-Young, 2008; Yaqoob, 2008). Many Muslim women cite the impact of hijab on their self-esteem as positive, and

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comment that the emphasis it places on behavior rather than appearance reduces how much they are objectified by society (Hyder et al., 2015). Emotional Health Emotional health and mental health are closely intertwined, and emotional health often serves as the measure of mental health. Mental health is often measured by generalized sense of well-being expressed in the areas of happiness, life-satisfaction, and sense of meaning and purpose (Hodge, Zidan, & Husain, 2016b; OECD, 2013). However, these concepts have different cultural manifestations across national lines, races, and religions, depending on a variety of factors (Diener et al., 1995). Spiritual well-being has also been shown to be a predictor of happiness, and general well-being (Rowold, 2011) and generally R/S equate with greater emotional and mental health (Koenig & Shohaib, 2014). A meta-analysis of 147 studies on the effect of religion on depression also showed a mild association with fewer symptoms (Smith, McCullough, Poll, & Cooper, 2003). Muslim women and emotional health. Muslim women’s R/S have been found to contribute to their emotional health in the areas of happiness, life satisfaction, and sense of meaning and purpose. Muslim women’s emotional mental health benefits from their religion in its emphasis on spiritual connectedness and personal direct relationship to God, unmediated by religious authorities (Ahmed & Reddy, 2007; Haddad et al., 2006; Kakoti, 2012). Prayer can also positively contribute to emotional health among Muslims (Hodge et al., 2015). Muslim women and happiness. Among Muslims generally, R/S have been found to positively correlate with less depression (Koenig & Shohaib, 2014; Hodge et al., 2015;

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Hodge et al., 2016a). However, the question of whether or not happiness correlates more highly with R/S is less well-investigated, and there is some evidence that there is a negative relationship between happiness and religiosity (Lewis & Cruise, 2006). In some research, the correlation between happiness and life satisfaction is affected by fear of happiness. Particularly among collectivist cultures, fear of happiness affects people’s report on scales such as the Satisfaction with Life Scale (SWLS) and lowers their tendency to report high levels of happiness regardless of their levels of overall satisfaction with life (Joshanloo, 2012). In fact, there is in Islam somewhat of a trend towards societal disapproval of happiness, common to many cultures (Joshanloo & Daemi, 2015). Happy people are often seen as shallow, or vulgar, while sadness is equated with personal depth (Joshanloo, 2012). In spite of this, the preponderance of evidence indicates that happiness is positively related to religiosity among Muslims, as shown by studies in Kuwait (Abdel-Khalek, 2006), and Algeria (Abdel-Khalek & Naceur, 2007). Muslim women and life satisfaction. Studies of Muslim women show an association between R/S and life satisfaction. In a study on Muslim women and their religious support, Bjorck and Maslim (2011) found that religious support correlated with higher life satisfaction (p. 62). Koenig and Shohaib report that there are 20 quantitative studies that all show a significant positive relationship among Muslims between R/S and well-being as measured by life-satisfaction and happiness. In another study, R/S was shown to have a complex but positive impact on life-satisfaction and subsequent positive mental health outcomes in Muslim women in Australia (Jasperse, Ward, & Jose, 2012).

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Studies have also shown a positive connection between R/S and life satisfaction among Muslim women in Pakistan (Khan et al., 2015), and Algeria (Abdel-Khalek & Naceur, 2007) Muslim women and meaning and purpose. Islam teaches Muslims that everything that happens is for a reason, and that because God is all-powerful, everything that happens is a result of Divine Will. Thus, Islam teaches Muslims to have trust in Allah and be patient in times of distress (Aflakseir, 2012). Islam means surrender, and the religion is based on submission to the Divine Will. As a result, it is predictable that Muslims would have a strong sense of meaning and purpose at all times in the face of a variety of life events. Koenig and Shohaib (2014) report that they found three studies that measured meaning and purpose as connected to R/S and that all three found significant positive relationships between the two (p. 177). Studies have also found a connection between R/S and meaning and purpose among Muslim women in Pakistan (Khan et al., 2015). Among Muslim students in England, sense of meaning and purpose derived from R/S was linked to well-being (Aflakseir, 2012). Conclusion There is significantly more psychology and social work research conducted among non-Muslim subjects than on Muslim subjects in the West (Bjorck & Maslim, 2011; Graham et al., 2009; Hodge et al., 2016b), and much of the literature on multiculturalism does not directly address the needs of Muslims (Graham et al., 2009). In the area of R/S, the majority of the research has focused on Christian subjects leaving

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a large gap with regard to knowledge of the role of R/S for Muslims (Bjorck & Maslim, 2011; Koenig & Shohaib, 2014). The growing need for services for Muslims highlights this gap (Graham et al., 2009; Hodge et al., 2016a).

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CHAPTER THREE: METHODOLOGY Research Question and Hypothesis The main research question of this study is “How does Muslim women’s religion and spirituality (R/S) operate as a protective factor (PF) in their mental health?” Three specific areas of inquiry are the relationship of R/S to social support, self-esteem, and emotional health and how these factors contribute to mental health. This researcher hypothesized that Muslim women’s R/S positively impact their sense of social support (defined as felt sense of peer support, community support, and family support), selfesteem, and emotional health (defined as happiness, life-satisfaction, and meaning and purpose). Methods Design This study used a mixed methods approach. The qualitative component involved one-on-one interviews with mental health professionals and focus groups with community women. Obtaining information from clinicians was expected to provide insight into the community, as a whole, from the point of view of key informants. The clinicians were expected to have a broad understanding of the Muslim community from their work, and to be able to reflect on how mental health affects Muslim women from the perspective of women who have a strong understanding of mental health. Obtaining information from community women was expected to provide information about a range of perspectives on how R/S exert a protective effect on Muslim women’s mental health. The quantitative component was comprised of administering two scales, one on

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religiosity and the other on life satisfaction. These two measures were included to provide indicators for participants’ intensity of R/S and mental health. The Institutional Review Board of California State University, East Bay approved all study procedures. Study Setting This study took place in the East Bay, South Bay, and North Bay of the San Francisco (S.F.) Bay Area. With roughly 250,000 Muslims, representing 3.5% of the population, the Bay Area has one of the highest concentrations of Muslims in the country (Senzai & Bazian, 2010). Focus groups were held in the Berkeley Masjid, the Muslim Community Center located in Pleasanton, and a private home in Marin. Interviews with clinicians took place in cafes, parks, and private homes. Sample A convenience sample of 20 women was recruited. There were two subsamples, one of mental health professionals and one of community women. The mental health professionals and community women were recruited with a snowballing approach. For the clinician sample, the main source of recruitment was a Google group for Muslim mental health professionals. To qualify for the study, clinicians had to be 18-65, be Muslim, and be working in mental health, and have at least a Master’s level degree in mental health or be students in a Master’s program. Eight women were recruited for the clinician sample. The researcher recruited community women at masjids and online, announcing the study at community events and distributing flyers, and sending out emails with the flyer to potentially interested community members. Women had to be 18-65, had

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to have been living in the Bay Area for two years, and had to have been Muslim for five years. Twelve women were recruited. Instruments The instruments used were a demographic questionnaire, the Duke University Religion Index developed by the Center for Spirituality, Theology and Health, at Duke University Medical Center (Koenig & Büssing, 2010), and the Satisfaction with Life Scale developed by Diener, Emmons, Larsen and Griffin (1985) at the University of Illinois. The demographic questionnaire was created by the researcher to collect information regarding age, ethnicity, level of education, marital status, employment status, length of residence in the S.F. Bay Area, and length of residence in the U.S. Additionally, clinicians were asked about length of time working in mental health and if they were licensed. The Duke University Religion Index. The Duke University Religion Index (DUREL), developed for use with Judeo-Christian-Islamic traditions, has been used in over 100 published studies and is available in 10 languages (Koenig & Büssing, 2010.) It contains five items that evaluate level of religious involvement, including organizational religious activity, non-organizational religious activity, and intrinsic religious activity (Koenig & Büssing, 2010.) Organizational religious activity for the Muslim version of the scale is defined by attendance at the mosque (Koenig & Büssing, 2010). Nonorganizational religious activity is defined by concrete behaviors such as prayer or reading the Quran that are done individually (Koenig & Büssing, 2010). Intrinsic religious activity is defined by internal beliefs and attitudes pertaining to the Divine, such

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as how much one’s faith influences one’s life (Koenig & Büssing, 2010). The items of the scale are rated on a Likert scale. Organizational religious activity (ORA) and nonorganizational religious activity (NORA) are rated on a scale of 1-6 (1 - Rarely or never; 2 - A few times a month; 3 - Once a week; 4 - Two or more times/week; 5 - Daily; 6 More than once a day). These questions are “How often do you attend the mosque or other religious meetings?”- (ORA(1)), and “How often do you spend time in private religious activities, such as prayer, meditation or Quran study?”- (NORA(2)). Intrinsic religious activity (IR) is rated on a scale of 1-5 (1 - Definitely not true; 2 - Tends not to be true; 3 - Unsure; 4 - Tends to be true; 5 - Definitely true of me) based on three items which include “In my life, I experience the presence of the Divine (i.e., God)” – (IR(3)); “My religious beliefs are what really lie behind my whole approach to life” – (IR(4)); and “I try hard to carry my religion over into all other dealings in life” – (IR(5)). The scale has been found to have a high test-retest reliability (intra-class correlation = 0.91), high internal consistence (Cronbach’s alphas = 0.78–0.91), and high convergent validity with other measures of religiosity (r = 0.71–0.86) (Koenig & Büssing, 2010). Additionally, the DUREL, modified for Islam with Iranian Muslims, was found to have similarly high testretest reliability (intra-class correlation = 0.937-0.991) and high internal consistency (Cronbach's alpha = 0.866-0.921) (Saffari et al., 2013). The DUREL has also been used in multiple studies with Muslims to study PFs in countries such as Malaysia and Indonesia (Koenig & Shohaib, 2014). The Satisfaction with Life Scale. The Satisfaction with Life Scale (SWLS) is a five-item measure of global life satisfaction rated on a Likert Scale from 1 (strongly

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disagree) to 7 (strongly agree) (Diener et al., 1985). According to Pavot and Diener (1993) most groups fall in the range of 23 to 28 or the range of slightly satisfied to satisfied. It is a widely-validated instrument (Pavot & Diener, 1993; Vassar, 2008), with a meta-analysis showing a Crohnbach’s alpha of .78. The SWLS has been used in a variety of cultures and age groups and was shown to have a higher degree of validity in samples of women (Vassar, 2008). Many studies of PFs among Muslims have utilized the SWLS (Koenig and Shohaib, 2014). Interviews with Mental Health Professionals Female Muslim mental health professionals (n = 8) were interviewed individually about what they saw as the strengths for themselves and for Muslim women in general who practice Islam and how R/S protect them personally and other Muslim women from mental health problems. The interviews were semi-structured and followed themes that were of particular emphasis in each particular interview, so due to the restraints of time, not all questions were answered equally in each interview (see Appendix A for the questions that comprised the outline of the interviews). The questions were focused on sense of social support, self-esteem, and experience of emotional health. The researcher focused on the positive influence of R/S and on how R/S protect and improve mental health, but there was room for comments on how R/S have a negative influence if the participants chose to make negative comments. The researcher followed an inductive approach, building themes as each interview progressed, and as the series of interviews progressed, into more abstract categories that included a variety of responses (Creswell, 20007, p. 45). Interviews lasted up to 60 minutes and were audio recorded. They took

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place at sites and times convenient to the interviewees, with the option of coming to a local masjid for the interview or meeting in a park or other public place close to their home or work. Two of the interviews took place in the participants’ homes. Participants completed the three study instruments prior to the interview when they arrived at the site of the interview on the day the interview occurred, as well as a consent form. Focus Groups with Community Women Muslim women from the community (n = 12) participated in three focus groups consisting of two to five women. Generally, women discussed how they saw their R/S as positively impacting their mental health. The questions were specifically focused on sense of social support, self-esteem, and experience of emotional health and followed the same structure as the interviews with clinicians (see Appendix B for the questions that comprised the outline of the interviews) with the exception that women were more encouraged to talk about their personal experience. Again, the researcher focused on the positive impact of R/S while room was made for negative comments if the participants chose to answer in this direction. Again, the researcher followed an inductive approach (Creswell, 2013, p. 45). Focus groups, lasting up to 60-90 minutes and audio recorded, took place at local masjids and a private home. Participants completed the three study instruments prior to the focus group when they arrived for the focus group as well as a consent form. Data Collection Procedure The PI conducted all individual interviews and focus groups and audio-taped them. Applying an exploratory strategy, she probed for additional issues based on the

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answers given to each open-ended question, with the objective of drawing out diverse conceptualizations and phenomena. Due to the limitations of time, and the exploratory nature of the study, not all women commented on each theme, but they were allowed to elaborate on areas that were of particular interest to them within the broad guidelines of the semi-structured interviews. Data Analysis For the qualitative data analysis, the researcher listened to audio-recordings of individual and focus group interviews and took detailed notes in MS Excel and MS Word. Coding involved the following steps: (a) listening to the interviews to note concepts, (b) grouping concepts to develop themes and initial codebook based on the interviews, (c) noting examples (i.e., quotes) for each theme for the interviews, (d) coding the remaining interviews again using the codebook while adding concepts and themes, and (e) reviewing the previously coded interviews again to code for the presence of added themes. A grounded theory approach was applied, which allowed for emerging themes and for the researcher to make decisions about the categories, bring questions to the data, and include personal values and priorities (Creswell, 2013, p. 88). For the quantitative analysis, descriptive statistics and correlations among sociodemographic variables, DUREL and SWLS were calculated using SPSS V24.0.

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CHAPTER FOUR: RESULTS Analysis of the qualitative data revealed that religion and spirituality (R/S), as hypothesized, function as a protective factor (PF) for mental health through its positive impact on social support, self-esteem and emotional health. However, for two variables, social support, and self-esteem, R/S also had a negative impact. The quantitative data did not reveal any significant relationships between any measured data sets. Sample Characteristics Clinicians. The sample of clinicians was a combination of licensed and unlicensed mental health professionals including Master of Family Therapy, Master of Social Work, and Doctorate of Psychology degree holders. The clinicians had been practicing from two years to 19 years. Ages for clinicians ranged from 24 - 47 and represented a variety of ethnicities: 75% South Asian and 25% mixed race. Marital status was varied, including 25% single, 62.5% married, and 12.5% divorced. Fifty percent of the clinicians were born in the U.S. while 50% had immigrated to the U.S. at some point. Focus group participants. For the focus groups, ages ranged from 29- 64, and participants represented a variety of ethnicities including South Asian, North African, Arab, Latino, and Caucasian. Educational background ranged from “some college” to “doctoral level degree.” Marital status was varied, including 66.66% married, 8.33% each single, divorced, engaged, and separated. Three women were converts, and the other 9 were born Muslim. Women had been in the Bay Area for a variety of lengths of time (three years – life). Two women had been born in the U.S., and all other women had immigrated to the U.S. at some point either in childhood or as an adult.

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Quantitative Findings Correlation Analysis No significant correlations were found between demographic data, SWLS, and DUREL scores (p>0.05, for all), and thus, no significant relationship between religiosity and life satisfaction was statistically identified, nor between any of the demographic data and the SWLS or DUREL variables (p>0.05). Thus the hypothesis that more R/S contribute to greater life satisfaction was not confirmed. The r-correlations (with p-values in parentheses) of scores on each item of the DUREL, ORA(1), NORA(2), IR(3), IR(4), IR(5), and the total DUREL scores, with the overall SWLS score were .084 (.726), .268 (.252), .029 (.904), .318 (.173), .068 (.775), .11 (.62), respectively. Several methodological factors may explain why the hypothesis was not supported including the small sample size and the homogeneity of the sample. There was a very low SD for some of the measures, particularly the DUREL items IR(3), IR(4), and IR(5), which shows the homogeneity of the sample, and the means were very high. The means for ORA(1) and NORA(2) were also high with slightly larger standard deviations than IR(1-3) but again the sample mostly fell on the high end of the scale. Due to the larger standard deviation of ORA(1), the non-significant relationship between ORA(1) and SWLS probably was not due to the homogeneity of the sample. The mean for the SWLS was at the very high end of the normal range which shows that a large portion of the sample falls above the normal range. The means (with standard deviations in parentheses) for ORA(1), NORA(2), IR(3), IR(4), IR(5) in the DUREL, total DUREL scores, and the overall SWLS score were 4.65 (1.38), 5.30 (1.21), 4.95 (.22), 4.95 (.22),

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4.80 (.41), 24.65 (2.23), and 27.40 (4.89), respectively. Organizational religious activity (ORA(1)) and non-organizational religious activity (NORA(2)) are scored on a scale of 1-6; intrinsic religiosity (IR(1-3)) is on a scale of 1-5. The high score for SWLS is 35 with most populations falling between 23 and 28. Qualitative Findings Thirty themes were detected across the three variables. For social support, there were 10 positive themes (sense of belonging, values, learning, peer support, family, support for a variety of lifestyles, help in raising children, support for women, social justice, hijab) and two negative themes (lack of support for woman in the masjid, cultural and ethnic divisions). For self-esteem, there were nine themes (essential value as a human being, pride in being Muslim, strong values, caregiving and service, education and learning, stories, prayer, a holistic approach) and two negative themes (judgment, abuse). For emotional health, there were five themes (gratitude, prayer, patience in adversity, social justice, belief in heaven). Two themes outside of the variables came up in the interviews and focus groups (Islamophobia, mental health). Five of the 30 themes stand out as going across variables (values, prayer, hijab, learning, social justice). The themes were largely shared between mental health professionals and focus groups, with 26 themes detected in both focus groups and clinicians; two themes detected only in individual interviews; and two themes detected only in focus groups. The major difference between the focus group women and the clinicians was the fact that the clinicians commented more on the negative mental health effects of R/S. All quotes cited in the qualitative findings use pseudonyms to protect the anonymity of the participants.

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Social Support R/S had positive and negative influences on social support. The data revealed 12 themes regarding social support across individual and focus group participants. The 12 themes included 10 positive themes (sense of belonging, values, learning, peer support, family, support for a variety of lifestyles, help in raising children, support for women, social justice, hijab) and two negative themes (lack of support for woman in the masjid, cultural and ethnic divisions). One theme was exclusive to focus group participants. Each theme is described, including any sub-themes, and illustrated with quotes from study participants. Sense of belonging. The most pervasive theme in the area of social support was the sense of belonging that women expressed in relationship to other Muslims. Nineteen out of 20 of the women expressed that they felt a strong sense of belonging in the community centers and masjids. One focus group (FG) participant said, “I found no matter where I go I can always connect to the Muslims, that I can go to the masjid. I can start to meet people, and that's the first step of making friends and building social supports" (Hasana, personal communication, September 5, 2016). She explained this was partly because Muslims share the same faith. Another FG participant stated that the connection to other Muslims that she felt had to do with shared values saying, “There is a strong connection just because we are all part of the same faith. So, there's already kind of an organic relationship there because we have similar norms and standards” (Hajar, personal communication, September 5, 2016). One clinician stated when a Muslim woman goes to a community center or masjid, “You enter into a nice, safe, space, where

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there are a lot Muslims. You know you don’t feel judged for being a Muslim so much so” (Ayesha, personal communication, August 9, 2016). Three women mentioned the sense of belonging when they attended prayer, both Eid prayer and Friday prayer, or prayer with family. Concrete support was another form of social support mentioned by women that contributed to a sense of belonging. Two of the focus group women stated that when they moved to the Bay Area, the masjid provided support for them in getting settled in the community. One woman said her husband had found a job through the masjid. Support from moral values. In both the masjid and the greater Muslim community, women reported that values played an important role in how their R/S affected their social support. Six women (4 clinicians, 4 FG participants) stated that the strong values that they learned and practiced as a result of their R/S were a big component in how their R/S supported them socially in their way of being in the world as individuals. One clinician commented, “Religion is a guiding force in terms of your relationship with the world, an internal relationship to Allah but also an external relationship to the world” (Khadija, personal communication, August 10, 2016). Another clinician called Islam “a guide to life” (Hafsa, personal communication, August 25, 2016). They talked about how it helped them to raise their children with strong values, or alternatively for young people, how it inculcated in them a sense of strong values which they found to be supportive and strengthening. Learning as social support. Three women (2 clinicians, 1 FG participant) reported on of the main values that supported social support in the community was learning. One clinician commented, “The Quran is dedicated to those who reason”

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(Ayesha, personal communication, August 9, 2016) and talked about how this led to open questioning that she thought supported women in the community. Positive peer support. R/S also contributed to perceived peer support. Five women (4 clinicians, 1 FG participant) responded to the question of peer support by saying they felt their R/S were crucial elements in how they or other Muslim women they know connected to peers. They said the reason was the importance of forming bonds with people who understood and shared their values. A clinician stated, women “can go to any place in the community, even if people are less religious than you, we all believe in God. We all believe in certain values. We all share a struggle” (Sonia, personal communication, August 25, 2016). Several women commented that they see the conflict of Islamic values with societal values as standing in the way of relationships with non-Muslims. One clinician (Maryam) commented that there is often a conflict between progressive values and religion in some circles which make it much easier for her to connect with Muslims than peers in a more secular environment. One clinician also said Islam “teaches us to be loyal to our friends,” and that Islam gives her guidance in how to how positive relationships with peers citing the example of how the Prophet’s companions are still remembered and respected for their close connection to him (Khadija, personal communication, August 10, 2016). Family support: R/S as guidance and hindrance. The women varied in their response to how important R/S were to their connection to their families. Five women (4 clinicians, 1 FG participant) said that family was very important and central to their R/S and cited reasons such as a religious upbringing, emphasis on helping parents, and the

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impact of their R/S on their relationship to their children. Several women stated their R/S gave instructions and guidance on how to relate to their families, particularly parents and husbands. One FG participant stated, “Religion gives you instructions. For example, a husband to provide for his wife and provide for his children. How to treat people, treat others with kindness” (Zahra, personal communication, September 9, 2016). A clinician said, “Islam talks about being a daughter, to be respectful to parents, to have good communication with them” (Hafsa, personal communication, August 25, 2016). Two FG participants talked about how Islam teaches sabr, or patience and how this helps them to deal with family in positive ways. Seven women (3 clinicians, 4 FG participants) said there was also a negative component of the masjids in regard to pressure to conform to a certain type of lifestyle, particularly in response to women that were not married. One clinician stated that single women are “not so supported” and that there is more of a need for this (Hafsa, personal communication, August 25, 2016). Three of the women (1 clinician, 4 FG participants) who were divorced voiced that it was sometimes difficult to be in the community as a divorced woman, and that there was a stigma attached to being divorced even though it is permissible in Islam. However, two of the divorced women expressed that while being divorced was difficult, their R/S also helped them to cope. One woman said her R/S had given her comfort in hard times. She quoted a verse in the Quran saying, “Verily with the remembrance of Allah do we find peace and tranquility” (Hajar, personal communication, September 5, 2016).

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There were mixed responses on the impact of R/S on being single. One clinician who had never been married was very vocal in her criticism of the pressure within the community to be married and the difficulty of being single (Sonia, personal communication, August 25, 2016). However, another woman (Sakhina) who was single said she felt that Muslim family and friends were supportive of Muslim women being single and that for her personally, since both her sisters were single, it felt normal to be single. Another clinician said she felt single people, “have their own spaces” (Fatima, personal communication, August 16, 2016). There was a range of responses on the impact of the religion on raising children. Two women commented that their children had experienced challenges growing up and that they felt marginalized by the community as mothers. One woman had a child with autism. She criticized the community saying that the community “is very comparative and competitive for our children” (Amina, personal communication, September 9, 2016). Another FG participant (Jamila) had a son with ADHD. She described similar issues. However, it was stated that this is a problem with the larger community. A third FG participant (Saida) stated that the masjid had helped her in raising her son through a Sunday school group. One clinician (Fatima) stated she felt that being a mom made it necessary to focus more on her R/S and that R/S were supportive of creating a supportive environment for raising children. A FG participant (Zubaida) commented that when she gave birth and had to have a C-section, the support from other women was critical in her recovery because they brought her food and she didn’t have to cook.

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Problems with social support in the community. Five women (4 clinicians, 1 FG participant) criticized local community centers and masjids for being less friendly and supportive of women than men. Two women (1 clinician, 1 FG participant) commented that while they were growing up, there were unequal educational opportunities for girls and boys, and this negatively impacted their ability to learn to practice their R/S. However, they both commented that in recent years, this had been changing and one of them (Amina) said that she had become a Sunday school teacher to respond to this need. Several women commented that many community centers had smaller and worse spaces for women and that this posed a problem for them especially when they wanted to attend prayers and events with their children. One clinician (Fatima) said that in some masjids, “The women’s area is beyond tiny. Going with a toddler, I don’t even want to bother” (Fatima, personal communication, August 16, 2016). However, she said this was only true in some masjids and that there were larger community centers where she felt comfortable. The problem for her was that these centers were farther away and it took longer to get to them. Several women (2 clinicians, 3 FG participants) gave a contradictory viewpoint to the criticism of women’s spaces and stated that they felt that they were accepted and supported as women by the community and that the smaller prayer spaces for the women made sense, as community prayer is not obligatory for women. One clinician stated that masjids have a lot of spaces for women, including opportunities to volunteer, offer encouragement for civic engagement, and women’s halaqas (Arabic: religious study groups.) One clinician (Sakhina) talked about how she had organized women’s groups for

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years and how much women had enjoyed participating in these groups. She commented that it would strengthen the community if there were more spaces outside the masjid for Muslim women to meet. Additionally, one woman was vocal in expressing that the West’s treatment of women was worse than the treatment of women in Islam and questioned the portrayal of Western feminism as a solution to women’s problems. She stated, “The 1970s was about women’s liberation but the women’s liberation we got from the West was a joke” (Maha, personal communication, March 13, 2017). She also said that her resistance to feminism has alienated her from some people in society. She stated, “I balk at so many things, particularly the view of women in the West, which I find very unfortunate, and very repressive in a different way, and very dangerous. Then I can be viewed as a very conservative person with backward ideas” (Maha, personal communication, March 13, 2017). Overall, the comments on the impact of R/S on being a woman in social settings were mixed. Ten women (4 clinicians, 6 FG participants) criticized the community centers and masjids for being very ethnically separated and for the negative impact of culture, both on the expression of the religion and the role of culture in dividing the community. One FG participant stated she thought it was an important area of needed growth for the community. She said, “I’ve been over 35 years in America and every community that I’ve gone to every single community that I’ve gone to, Pakistanis stick there, and Afghans stick there, Indians stick there. So, you know, we like to say we’re integrated but you know we’re not” (Jamila, personal communication, September 9, 2016). There were

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contradictory statements to this though including a woman who is Cuban-American, a convert, and a FG participant who stated, “I went to the masjid in Concord and I studied the Quran. I started with a group of people from very different places. They have people from Afghanistan people, from Pakistan people, from Egypt, the teacher was from Egypt, and I felt so welcomed” (Karima, personal communication, September 9, 2016). Several women commented that these cultural divisions as well as cultural interpretations were not part of the religion of Islam and that it was a universal problem among all religions. One FG participant said, there is “one Islam and many cultures, and there are some interpretations that have made religions, all of them, very strange” (Maha, personal communication, March 13, 2016). Like the responses on the impact of R/S on the participants as women, the responses about the impact of culture and race on R/S were mixed. Social justice and social support. When asked about social support some women (2 clinicians, 3 FG participants) emphasized the importance of social justice. One FG participant (Maha) tied the Islamic emphasis on social justice into many of the already mentioned themes, including her relationship to the masjids and community centers, her relationship to peers, the importance of values, and her decision to wear the hijab. She talked about the importance of giving to the masjid as a response to the teachings of social justice. Concerning values and peers she said, “Islam stresses social justice. Some religions encourage people to be charitable, but they don’t make it a part of your everyday life. When we interact with other people, you are more aware that you are doing it” (Maha, personal communication, March 13, 2016). She stated that the example of the

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Prophet framed her entire relationship to the world by making fundamental principles of justice and fairness central. She stated, “We learn from the example of the Prophet, sallahu alayhi wa sallim (Arabic: peace be upon him,) what would he do? Get along and be just. It’s pretty darn simple. It’s like, who would Jesus bomb?” (Maha, personal communication, March 13, 2016). Hijab and social justice. The emphasis on social justice and resulting political engagement tied into many themes, one of which was the hijab. Two FG participants said they had put on hijab as a response to the political situation and that this had been a recent response for many Muslim women. On hijab, one FG participant commented, “No one wore hijab 30 years ago” (Maha, personal communication, March 13, 2016). She said the decision to wear hijab for her was very political. She stated, “9-11 happened, I went, ‘Oh My God.’ People give hijab way too much importance or not enough. After 9-11 I was inspired to wear it. It’s political. No, nobody is forcing me. You come visit my household; you’ll see who rules this show. (Everyone started laughing)” (Maha, personal communication, March 13, 2016). She said immediately before she started wearing it all the time, she put on hijab and people said she looked like a Muslim, and this made her think she should wear it all the time to be more assertive about her identity. Another FG participant (Jamila) also stated she had put on hijab recently due to a desire to be visibly Muslim in her community in response to Islamophobia, particularly in her children’s school district. Hijab and social support. Seventeen of the 20 women wore hijab with two clinicians reporting not wearing it and one FG participant reported sometimes wearing it.

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Most of the ten women (2clin, 8FG) who commented on wearing hijab stated it contributed to beneficial social support. The women who commented that hijab improved their social support said it contributed to other women saying salaam (Arabic: peace, the traditional greeting) to them in the community and made it easy for other Muslim women to identify them and reach out to them. A FG participant said, “Especially around, wearing hijab just walking around town, or something, you might be someplace you never been and you may see a stranger and they may give you salaam. You're like, ‘Oh there's Muslims here. People value me’” (Hasana, personal communication, September 5, 2016). One clinician (Sonia) stated that beneficial social support helped to deal with the pressure of wearing a hijab in the current political climate. Another woman (Amina) who wears the hijab said that she had been wearing a hijab for 20 years, and the current political climate had made it much more difficult to be visibly Muslim. One clinician who does not wear a hijab said she had stopped wearing the hijab in part due to Islamophobia making it too much of a burden. The one FG participant that did not wear hijab all the time said, “One day I was in Costco, and someone asked me is someone forcing you to wear hijab” and asked her if she was OK (Nabila, personal communication, March 13, 2017). She said her response was, It’s my wish. One day I’ll go to Costco with the hijab. One day I will not go to Costco with my hijab. It’s my preference or how I feel on that day...it’s different for me. Some people chose to wear it all the time but I do it occasionally. I want to have the privilege of being whoever you want to be and I don’t want to be perceived as a stereotype...I want to be free. Wear it. That is my freedom. Don’t wear it. That is also my freedom (Nabila, personal communication, March 13, 2017).

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Self-Esteem Women unanimously reported that being Muslim supported their self-esteem and that it was for a variety of reasons. These included the belief that they were created by God, the virtues of modesty, and other strong ethical values that went along with being a Muslim, including service to others, and learning. Several of the themes that came up in the topic of self-esteem overlapped with the themes that came up with social support including the importance of strong values, prayer, learning, and hijab. There were a total of 11 themes for self-esteem. These included nine positive themes (essential value as a human being, pride in being Muslim, strong values, caregiving and service, education and learning, stories, prayer, a holistic approach) and two negative themes (judgment, abuse). The essential value of the human being. Nine women (5 clinicians, 4 FG participants) commented that they felt either them themselves, or Muslim women generally, felt self-esteem due to the essential value of being human in relationship to a good God and Creator. One clinician (Ayesha) talked about how in Islam there is the belief that people are all born in right relationship to God, that the fundamental nature of people, or fitra, is seen as good. One FG participant said, “With religion, Allah created everybody and everybody has worth whether we recognize it or not” (Hasana, personal communication, September 5, 2016). Several women explained that they felt self-esteem because they believe God loves them. One FG participant said, “Nobody can love their kids like me and knowing that Allah loves us more than that, Yanni (Arabic: you know), Subhanallah (Arabic: glory to God)” (Hajar, personal communication, September 5, 2016). God’s forgiveness was also given as a reason for feeling self-esteem in spite of

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making mistakes. One FG (Amina) participant said that her God given nature as a human being who errs helps her to accept her mistakes. A clinician said, “God loves me and forgives me so I love myself and the people around me. There’s no point in having low self-esteem. We're human. We do make mistakes” (Khadija, personal communication, August 10, 2016). One clinician (Maryam) said she thought that Muslim women sometimes internalized negative images of women in a way that decreased their selfesteem and made them feel less valuable than men, but she stated that she felt this was a part of a larger universal human problem with patriarchy as well as a tendency across religions to use scripture to oppress women. Pride in being Muslim. Two of the clinicians stated they believed Muslim women have a pride in themselves as Muslim, and the focus groups all reflected this sentiment at one point or another. One clinician said, “I mean Allah had the Angels bow to Adam. We don’t want to take it to the extreme and be prideful. But there’s I think a lot of underlying value of the human being in Islam” (Ayesha, personal communication, August 9, 2016). Another clinician said, Our religion is such a big part of our identity, especially nowadays with everyone that is going on in the news and you know in the world with politics more women, especially in the Bay Area, are proud to wear it on their sleeve, that hey, we’re Muslim. Look at me. Come talk to me. Especially in the Bay Area there are a lot of women who wear full on niqab (Arabic: the full veil that only shows the eyes) and they have no hesitation about it...They’re proud to do it. They love when people stop them like in the shopping centers and want to talk to them and stuff like that. For women, our religion increases their self-awareness and their selfesteem (Fatima, personal communication, August 16, 2017). Both clinicians and FG participants talked about how their identity is primarily as Muslims. In the past, they said, they had been Afghani, or women, or Americans. With

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the increase in Islamophobia, and the negative images of Islam and Muslims in the media, they had responded by identifying more with themselves as Muslims. Strong values. Five women (4 clinicians, 1 FG participant) talked about the importance of values for either themselves or for Muslim women in fostering self-esteem. Three women (2 clinicians, 1 FG participant) specifically mentioned the importance of the value of chastity. They talked about how in the broader society women link their selfesteem and their self-respect to men and said they feel that Islam protects women from that behavior. One clinician said, “A lot of girls get stuck on getting attention from a man and they forgo their self-respect to do that. Our religion teaches us to hold off on that” (Sakhina, personal communication, January 10, 2017). She said she has seen the impact of this for good on women who have internalized the Islamic value of chastity and damaging for women who have not. One FG participant stated that she gets self-esteem from the value of speaking up for the values religion gives her. She said, I want to do the right thing, I believe in God, I want to uphold those values, I have stronger courage I have confidence, that is selfesteem, I might have temporarily...other people might not like me because I am open-mouthed, but I feel that I am doing things because of the underlying values (Saida, personal communication, September 9, 2016). Care-giving and service. Seven women (1 clinician, 6 FG participants) responded to the question of how R/S relate to self-esteem by talking about caring for the sick, or caring for others generally. One FG participant stated, To increase my self-esteem, I volunteered in a hospital, in a nursing home. When you volunteer, you get something, a feeling of gratitude. Your life is not as bad as you think. You are walking out of this nursing home. Praise be to God you can walk out. Yeah, I could go to

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therapy, but to go visit sick people was more productive for me. 70,000 angels may be praying for me. It gives you that positive feeling that I don’t think that therapy ever... (Amina, personal communication, September 9, 2016). Another FG participant stated, It comes to the same idea as the Prophet, peace be upon him. He purposely said, “I came to serve. I am not a king.” I think it was in relationship to how much things he had in his house and it’s described that he was very humble. And so, in that same idea how Islam teaches us to be humble, teaches us to serve others. In my case I asked my mother to come and live with me. And she was living in New York and she was living in…Compared to the conditions she could live with me it was not as good as the ones that she could have. And so, I beg her to come to California, and she did, and so I felt that that was you know in my religion I learned that the doors for Jannah (Arabic: heaven) is at the feet of your mother. And so, having her in my house was actually bringing the doors of Jannah closer to me...so I do it because I am getting rewarded by Allah. When we use servant here in America people feel that you are less but I feel that I am not less. It makes me feel strong and big… (Karima, personal communication, September 9, 2016). Another FG participant (Uzma) stated, “When you are able to come out of the me zone, that is for me when I able to serve more and able to do more. That is the self-esteem” (Uzma, personal communication, March 13, 2017). She said Islam teaches us “how to give your helping hand to another” and how this is important to her self-esteem and for other people’s self-esteem (Uzma, personal communication, March 13, 2017). Another FG participant stated, “You give out of your good deeds. You give out of your time you get out of your caring. If you have time to go meet old people you go do that because this is all part of Islam. I feel that’s relating to self-esteem” (Zahra, personal communication, September 9, 2016). Education and learning. Five women (2 clinicians, 3 FG participants) talked about the importance of the Islamic emphasis on education and learning and how this

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supports their self-esteem. One woman stated that her parents taught her that Islam teaches for people to “learn from cradle to grave” and that this supports her in making a positive contribution to the world, and therefore her self-esteem (Jamila, personal communication, September 9, 2016). One FG participant talked about how for the women of her focus group, Islam teaches women to be educated and said, “We are very well-educated. Our interpretation is that women will go forth; other interpretations are that women are to stay home. Sexism is a world-wide thing. Islam provides for an opportunity to clear this misunderstanding” (Maha, personal communication, March 13, 2017). One clinician commented that, “God is like nothing else. You cannot know what God is” As a result she said, “There’s an intellectual inquisitive allowance in Islam” and that “the ability to grow and ask questions builds self-esteem” (Ayesha, personal communication, August 9, 2016). She made the connection that the total transcendence and unknowability of God in Islam precludes any final answers and “opens the door” to individual exploration of truth (Ayesha, personal communication, August 9, 2016). One clinician said, “Islam is education...I am Muslim by studying. Anything you study, when you work on yourself, is Islam” (Sakhina, personal communication, January 10, 2017). Stories. Three women (1 clinician, 2 FG participants) brought up the importance of stories from their R/S as contributing factors to self-esteem. One FG mentioned the story of Prophet Yusuf (Joseph) and how he was imprisoned in spite of the fact that he had done nothing wrong. She said that knowing “you can come up” encourages people when they feel low self-esteem (Nabila, personal communication, March 13, 2017).

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Another FG participant talked about how she gets encouragement from the seerah, the stories of the life of the Prophet (PBUH). Prayer. Another woman said prayer, or salaat, improves self-esteem. She said, “You are getting purified. You are purifying your soul and your heart feels brighter and your mind is also focused” (Nabila, personal communication, March 13, 2017). She stated that this gives her self-esteem. Holistic view of Islam. Two clinicians commented on how a holistic view of Islam supports self-esteem. One clinician (Sakhina) talked about how she sees what you eat, exercise, and how you spend your time as an important part of self-esteem. She talked about how a lot of people tend to disconnect R/S from the rest of their lives while she sees Islam as connecting to all areas of life. She mentioned that she has a holistic view of prayer. She described how she sees everything as prayer in one form or another and described her prayer life as including her self-care and her work. Negative impact of R/S on self-esteem. As mentioned above, the clinicians talked more about some of the negative impact of R/S on Muslim women. Two clinicians and one FG participant (Sonia, Maryam, Maha) commented on the problem of being judged. Each of them mentioned this in connection to being judged for not wearing the hijab and related how upset they were that other women had felt marginalized for this reason. Other ways they mentioned being judged were by being outside of the mainstream, or not following all the rules of the religion. One clinician talked about the problem of abuse. One clinician said, “Being in the mental health role, I have had people come…There is a negative side to our religion with self-esteem…there is a problem with

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abuse…As a community, as a whole, we are not accepting of that. Because of that the people who are abused, the victims don’t get the support they need and that makes them pull away from the religion even more” (Fatima, personal communication, August 16, 2016). She said the attitude can sometimes be that the image of the community is more important than helping the victims. However, she commented that this problem is present in all religious communities. One clinician (Maryam) talked about the impact of culture on patriarchy and said a lot of the immigrant community carries cultural beliefs about Islam and particularly about women that are not Islamic. She believes these cultural biases contribute to low self-esteem and/or oppressive practices, but said that she felt this was a larger problem in human society. Emotional Health Women reported unanimously that their emotional health was positively impacted by their R/S. All the women reported their level of happiness, life satisfaction, and sense of meaning and purpose were improved as a result of being Muslim. However, three of the clinicians commented that they felt that this was not the case for all women in the community and that they had seen how a fear of being judged had led to religious guilt, or self-criticism that was detrimental to women’s emotional health. In total, there were five themes in response to the questions of emotional health (gratitude, prayer, patience in adversity, social justice, belief in heaven). Prayer. In response to the question of happiness, ten women (5 clinicians, 5 FG participants) responded that prayer helped them be happier. One clinician stated, Being a Muslim woman, and practicing and feeling spiritual and connected to God really does support emotional health. . . .For me,

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personally when I am feeling a little depressed or down I can turn to Allah I can read verses in the Quran and it completely changes my mood and I have experienced within my family, people who have mental illness, for example, depression, obsessive compulsive disorder, anxiety disorder, bipolar disorder, and when they’re at the height of their anxiety, they can sit down read a few duas (Arabic: prayers) about lessening their anxiety or their feelings of depression and in that moment it can help them (Fatima, personal communication, August 16, 2016). She also commented that she said that she knew people who had been suicidal, and they didn’t kill themselves because the religion prohibits it. Other participants also said Islam had helped them when they were severely depressed not to commit suicide or to pull out of depression. One FG participant said, When I am depressed, I make my own songs, praising God, using God’s 99 names, when I say, “Ya, Rahman. You’re Rahman. I’m in need of your mercy. You are my God. You are the controller. I am in need of your qualities so please bestow them on me” (Saida, personal communication, September 9, 2016). Another FG participant talked about how telling God her problems made her feel like someone would help her. She said, “I can’t be with my family sometimes. I can only sit there and talk to God and when you keep sitting and crying, you feel that you have told another person and they are going to take care of it” (Hina, personal communication, March 13, 2017). One clinician (Sakhina) said the prayer puts people in synchrony because of the physical elements of the prayer. Gratitude. Additionally, nine women cited gratitude as being a source of happiness. The women mostly combined their answers on life satisfaction with their answers on happiness or their answers on meaning and purpose. The women generally reported high degrees of life satisfaction, saying that this was directly related to their R/S. The nine women (5 clinicians, 4 FG participants) who commented more extensively on

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life satisfaction cited gratitude as the main reason for their satisfaction with life. One clinician said, “Islam is about gratitude. It’s about appreciating what we have” (Sakhina, personal communication, January 10, 2017). One FG participant said, "With submission comes gratitude” after saying that submission to God is the central truth of her life that gives her happiness, life satisfaction, and meaning and purpose (Hina, personal communication, March 13, 2017). Another FG participant said, “Whatever Allah has blessed you with that is also a sense of happiness, just breathing, just free air. There are people who need to be in the ICU to breathe” (Nabila, personal communication, March 13, 2017). Another FG participant talked about her R/S as sufficient reason to be happy and grateful saying, “I am very happy because I am Muslim. I feel like it is a gift. Just that right there is enough” (Hajar, personal communication, September 5, 2016). Patience in adversity. Fifteen women (6 clinicians, 9 FG participants) commented that their R/S gave them patience in adversity in some way. They reported this mainly in response to the question on meaning and purpose, but their answers also crossed over into the areas of life satisfaction and happiness. Two women stated that their R/S were based on the belief that Islam means to submit to God and that this submission teaches them acceptance of everything that happens. One FG participant said, “You don’t have to have anything to see the beauty of the universe. You practice acceptance…a terrible situation has occurred but I’m just going to submit” (Maha, personal communication, March 13, 2017). Another FG participant said, “Acceptance comes from submission” (Zahra, personal communication, September 9, 2016). Two women reported that their belief that there is a reason for everything gives them patience. One woman

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said, “Allah tests those who He loves. He keeps me through everything” (Hajar, personal communication, September 5, 2016). Other women (2 clinicians, 2 FG participants) also said that they believe that God tests people and that accepting that is part of their R/S. The concept that everything is God’s will was commented on by some women as well. Another clinician said, “When things don’t go my way I say this is my destiny” (Khadija, personal communication, August 10, 2016). One FG participant said, “No matter how much I want to control things, He is the ultimate controller” (Zahra, personal communication, September 9, 2016). Social justice and meaning and purpose. Four of the women (3 clinicians, 1 FG participants) commented that they feel that their R/S give them a political sense of meaning and purpose. The Islamic teaching about social justice was cited by one clinician (Maryam) as her major motivator in life. A FG participant (Hajar) said the central focus of her life is to promote Islam. She stated she uses much of her time to work with the media to create positive visions of Islam. Another FG participant noted that being in service to others gives happiness and gives life meaning. She said, “Let’s try to be more helpful and help others and then we will be more happy” (Rashida, personal communication, March 13, 2017). Belief in heaven. Some of the women (2 clinicians, 1 FG participants) commented that the belief in heaven gave them a sense of meaning and purpose. One clinician stated, “Women in general in the Bay Area have the same understanding. We’re here to raise a pious family and our end goal is to reach heaven” (Fatima, personal communication, August 16, 2016). Another woman commented, “Nobody wants to die,

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but this is not a final destination” and talked about how her R/S made her see her goal as the next life, not this life (Nabila, personal communication, March 13, 2017). Other Themes There were two themes that stood out that did not really fit into any of the categories, or in some way impacted all of them, Islamophobia and the status of mental health services and care in the community. While these themes were not specifically brought up by the interview questions many women commented on them. In particular, the women wanted to take time to make recommendations which the interviews allowed. Islamophobia. Six women (4 clinicians, 2 FG participants) commented on Islamophobia and said it has had a significant impact on their mental health or the health of women in the community. One of the clinicians said that her identity as an American was invalidated because she was a Muslim. She said, “It bothers me when people think I’m not an American. They’re entitled to be American and Christian, but I’m not entitled to be American and Muslim” (Khadija, personal communication, August 10, 2016). One of the FG participants (Karima) stated that she lost all her friends when she became Muslim. Another FG participant said, “If I was Christian I would have it much easier, because of Islamophobia. I have been wearing hijab for 20 years, but there is definitely this post terrorism stress disorder” (Amina, personal communication, September 9, 2016). Mental health among Muslims in the Bay Area. Because of the relationship of the topic to mental health generally, several women commented on the status of mental health in the Bay Area Muslim community and the global Muslim community. Seven women (3 clinicians, 4 FG participants) stated that stigma was an issue. One woman said,

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“I’m sure if I had a mental health issue, I’d be shunned. There are some educated and some very uneducated, just like anywhere else” (Jamila, personal communication, September 9, 2016). One FG participant said, “People are afraid to talk across the board in all communities” when the discussion turned to mental and social health (Maha, personal communication, March 13, 2017). Two women said that the lack of incorporation of Western approaches to mental health was causing damage to Muslims in the community who were experiencing mental health crisis. One FG participant (Hajar) said that some people consider mental illness to be caused by jinn (Arabic: spirits) and shaitan (Arabic: devils) and, as a result, believe that reciting Quran or prayers is the solution to mental health problems. She criticized this saying, “When someone has a broken leg you don’t take them to the masjid. You take them to the hospital” (Hajar, personal communication, September 5, 2016). Several women (3 clinicians, 6 FG participants) said there is a huge need for more mental health services in the community. Another FG participant (Zubaida) said of mental health services at her masjid, “We are not getting anything right now” (Zubaida, personal communication, March 13, 2017). Several of the women (2 clinicians, 1 FG participant) also commented on the growth of mental health in the Bay Area over the last ten years in response to community needs. One clinician stated that the field of mental health “is exploding” including services and knowledge of mental health (Ayesha, personal communication, August 9, 2016). She said she feels there is a natural connection between Islam and mental health due to the rigorous questioning that has always been a part of the intellectual tradition of Islam and the openness of a lot of Muslims to psychology. She said of the focus on

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mental health, “I also just think it’s very fitting for the Muslim community because I think that most of the Muslims I meet are kind of bright and psychologically minded anyhow. So, there’s not a lack or shortcoming of openness to it and awareness of it especially in the Bay Area” (Ayesha, personal communication, August 9, 2016). Both clinicians commented on the recent opening of centers dedicated to Muslim mental health, run by Muslims for Muslims.

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CHAPTER FIVE: DISCUSSION The study’s hypothesis that R/S are protective factors because of their impact on social support, self-esteem, and emotional health was confirmed even though a few negative impacts were also found with regard to social support and self-esteem. The diversity and uniqueness of the set of themes suggest a need for culturally sensitive intervention strategies that account for the complex and subtle nature of R/S as a protective factor. Culturally competent practice also highlights the need to tailor interventions to each individual. Given that there are almost two million Muslims in the U.S., there is no “one-size fits all” approach to Muslim clients that will always work (Graham et al., 2010). However, the unanimous response of the study participants that their R/S supported their mental health confirms the importance of gaining understanding of the impact of R/S and exploring how such knowledge can be incorporated to promote culturally competent social work and mental health services. Quantitative Findings The data analysis did not reveal any correlations between R/S and life satisfaction. However, there is a strong possibility of a ceiling effect which is widespread among measures of religiosity in highly religious populations (King & Crowther, 2004; Koenig, Wang, Zaben, & Adi, 2015; Slater, Hall, & Edwards, 2001). The scores for the DUREL and the SWLS were on the very high end of the scale, indicating that the ceiling effect could explain the lack of significant correlation between R/S and life satisfaction. Further research with more sensitive scales, across a wider section of the population, is necessary to more fully investigate this question in quantitative terms.

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Qualitative Findings Social Support While the quantitative data was inconclusive, the qualitative data showed strong connections between R/S and the increase in PFs among the study sample. With regard to social support, community support based on R/S is a critical piece of how Muslim women can strengthen their mental and emotional health. Women’s participation in Muslim community centers and masjids engendered a sense of belonging, which contributed to their feeling of calmness, security, and stability in their lives. The concrete support they found through the community, including furniture for new housing, help with moving, assistance in child-rearing, and help with finding employment, were also significant. With these findings in mind, social workers should be ready to encourage Muslim women to access these community based strengths (Hodge, 2005; Graham et al., 2010). For instance, if women are trying to build on their R/S and they attend a masjid or community center that they find unwelcoming, it can be recommended that they try another place given that there are significant differences between organizations. Not all Muslims, particularly recent immigrants, may be aware of the variety of options (Hodge, 2005). Even with the potential benefits derived from community support, social workers should be prepared to support their clients if they encounter some of the problems that study participants described, including challenges with being a woman in the masjid, cultural and ethnic divisions and idiosyncrasies, and the stigma and lack of information about Western approaches to mental health. The women in the study gave many

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recommendations on how to best approach these challenges. Women’s advisory boards, more women teachers, and improved spaces for women in the masjids were just some of these suggestions. Women also asked for greater education and support to their local imams and community leaders in order to facilitate both the exchange of information between Muslims and the greater community and more effective intra-community support. Overall, findings point to the importance of building connections between mental health professionals and religious organizations in the community as a key component in supporting Muslim clients to access resources in the community that they can utilize to their advantage (Graham et al., 2009). Many of these changes are already being implemented in the Bay Area in a variety of ways, and have already been identified as needs in larger studies such as the one conducted by Senzai and Bazian (2010) and in other literature (Canda & Furman, 2009). The recent growth of Muslim organizations intended to support mental health in the Muslim community reflects the awareness of the need to improve mental health services for Muslims. In particular, the stigma attached to mental health services among Muslims is currently being addressed by non-Muslims and Muslims. First, among nonMuslims there is the growth in the literature on culturally competent interventions, including how to minimize stigma. Among Muslims, there is growing support for mental health interventions that are based on modern, Western psychology and psychiatry as well as a revival of traditional Islamic approaches that are in sync with modern evidence based practices. One example of this is the Khalil Center, a center for Islamic counseling that

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opened offices in Santa Clara, in the S.F. South Bay, in October of 2015, and in Pleasanton, in the S.F. East Bay, in January of 2017. Self-Esteem The finding that R/S are associated with high levels of self-esteem for Muslim women confirms previous research. Combined with the knowledge that self-esteem is positively correlated with mental health, this information could lead to a number of interventions. Cognitive behavioral therapy (CBT) has been shown to improve mental health through improving self-talk and ways of perceiving the world. Spiritually informed CBT is an approach that modifies traditional CBT in culturally sensitive ways to utilize the strong positive messages of R/S in reframing cognitions of the self. Modifying CBT to fit with Islamic worldviews has been found to have positive outcomes for treating depression, anxiety, and psychosis (Hodge & Nadir, 2008). Hodge & Nadir (2008) suggests using Islamically based statements instead of the ‘I’ statements usually emphasized in CBT. For example, a clinician could use the following statement to express a person’s worth in Allah: “We have worth because we are created by Allah. We are created with strengths and weaknesses” (Hodge & Nadir, 2008, p.37). This is supported by the fact that the women often reported that their relationship to God as Creator, and the Forgiver of sins, supported their self-esteem. In order help clients formulate these types of statements it is important that clinicians familiarize themselves with the basics of the religion. This approach requires a commitment on the part of the clinician to have a genuine understanding of Islamic beliefs and tenets so that the intervention is not superficial and therefore ineffective (Hodge & Nadir, 2008; Rahiem &

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Hamada, 2012). In order to do this, clinicians could talk with a local imam (Hodge & Nadir, 2008) or attend classes or events at local masjids. It is also significant to note that in a study of Muslim social workers El-Amin (2009) found that 10 of 15 Muslim social workers in the study believed it to be inappropriate to broach the topic of spirituality with their clients unless it was “client-directed” or “client-initiated.” This finding indicates the importance of being tactful and sensitive to client needs when dealing with the topic of R/S. Emotional Health The main findings on emotional health also suggest the importance of culturally informed interventions, including the findings that R/S enhance participants’ sense of patience in face of adversity, and the importance of gratitude and prayer. Mental health professionals should consider supporting clients to access their R/S as a tool to cultivate emotional health, happiness, life satisfaction and a sense of meaning and purpose. First, the importance of R/S for the participants in coping with adversity is one of the major findings of the study. Again, spiritually modified CBT is an option to access the strength of religious coping. Some possible spiritually modified CBT statements to encourage religious coping drawn from participant statements are: “Everything happens for a reason; God is in control,” or “God gives us strength to bear whatever life presents to us.” In addition to spiritually modified CBT, other approaches such as Rogerian and humanistic approaches, or emotion-focused therapy can be useful techniques when working with Muslim clients. Rogerian therapy with its emphasis on unconditional positive regard can be healing for Muslim clients who have experienced being judged or

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marginalized for their religion (Canda & Furman, 2009). This is consistent with the study’s findings that Muslim women are experiencing benefit from their religion and discrimination in their lives in U.S. society (Amer & Ahmed, 2012). Second, the study supports prior research that shows the potential for prayer to improve emotional health. Prayer can help people cope in times of crisis. The participants’ responses highlight the possibility that religious coping with spiritual distress can lead to greater levels of well-being (Canda & Furman, 2009). Prayer can also help with maintaining emotional health through reducing stress and elevating mood. As an intervention, clinicians can discuss prayer with clients, and ask them how and if they are already using prayer. This requires organizations and individual clinicians to make a safe space for Muslim clients to say their five daily prayers. Many settings, especially low-income settings such as homeless shelters or mental health rehabilitation centers, do not provide this space, especially when clients do not have a private room. Conclusion Implications for Developing Spiritually Competent Services The importance of R/S to social support, self-esteem, and emotional health indicates that creating an environment which reflects spiritual competence is critical to the well-being of Muslim clients (Rahiem & Hamada, 2012). Spiritually competent work can be defined as work that supports clients’ ability to access their R/S as therapeutic tools and as valuable cultural capital. Just as a basic understanding of Islam is central to using spiritually modified CBT, understanding Islam is vital for having a positive therapeutic relationship with Muslim clients, both at the individual level and the agency

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level. Canda and Furman (2009) also cite the principles of value clarity, respect, client centeredness, inclusivity, and creativity as important foundations of the therapeutic relationship for spiritually competent work in mental health. In addition, they describe a process of spiritually informed organizational development that would support both clinicians and clients in being able to best develop the religious and spiritual resources to support mental health (Canda & Furman, 2009). The role of providing a safe environment is also critical to providing trauma-informed care to the Muslim community. As a part of trauma informed care, organizational structures have to support healthy expressions of spirituality. This organizational component is a central focus of SAMHSA's guidelines for trauma informed practice in mental health (Center for Substance Abuse Treatment, 2014). This is especially critical due to trauma among Muslims from discrimination in the U.S. and the extremely high levels of trauma among immigrants. Negative mental health outcomes due to discrimination and negative stereotypes in the U.S. have increased in the current climate of hostility to Muslims (Hodge et al., 2015). In spite of all the negative stereotypes of the impact of Islam on Muslim women, this study showed a strong relationship between factors that support good mental health and R/S among Muslim women. This finding should encourage providers who do not already understand the positive elements of Islam to reject negative Islamophobic depictions of the religion, have an open mind about what it means to be Muslim, and to encourage Muslim clients to practice their religion (Graham et al., 2009). This may require self-reflection, journaling, and discussion of inclusivity to work through the

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societally imposed stereotypes of what Islam is, and who Muslims are (Canda & Furman, 2009). Implications for Promoting Respect and Inclusion of Muslim Culture Mental health providers can engage in this process of understanding Islam and what the religion means in the lives of Muslims in order to better support R/S of Muslim clients (Rahiem & Hamada, 2012). The findings in this and other studies of R/S as protective factors for mental health are grounds for solidarity with and support for the religious beliefs, observances, and identity of Muslim women from non-Muslim men and women (Abdullah, 2015; Rahiem & Hamada, 2012). The evidence that Muslim women, when asked, describe the many positive benefits of Islam on their lives contradicts the historical and current use of Muslim women’s oppression as a justification for antiMuslim laws, policies, and attitudes (Ebrahimji & Suratwala, 2011; Haddad et al., 2006). Muslim women are precariously situated between their oppression by the non-Muslim Islamophobic West and the patriarchal oppression experienced by women in Islam, an oppression that is mirrored in every culture and religion on the planet (Abdullah, 2015; Haddad et al., 2006). It is essential to this solidarity and support to allow Muslim women to exist as individuals, separate from the constant demand to denounce terrorism. The overall process and agenda of confronting anti-Muslim narratives is a part of cultivating our community and our shared values as Americans (Senzai & Bazian, 2010). Health professionals, as well as conscious members of the greater society, need to be in solidarity with Muslim women to claim their space, and their right to respect, civil rights and self-determination. This solidarity requires sharing the burden of denouncing anti-

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Muslim narratives and not expecting individual Muslims to have to declare their loyalty to human rights or peace in ways that single them out. Part of this process of solidarity, understanding, and support must involve incorporating R/S more fully in social work education (Oxhandler & Pargament, 2014). The alterity of Muslims in the U.S. has led to significant power imbalances, which is an important factor to understand and recognize for non-Muslims when working with Muslim clients (Andermann, 2007; Rahiem & Hamada, 2012; Smith et al., 2003). This power differential can be expressed as interethnic or interreligious transference on the part of the client, who tries to please the clinician because he or she is perceived to be affiliated with greater institutional or structural power in the society (Rahiem & Hamada, 2012). Sensitivity to this power imbalance is essential for clients to feel safe to express their experience accurately to clinicians. This power differential often manifests as Muslim and other people of faith being discriminated against by clinicians (Rahiem & Hamada, 2012; Hodge et al., 2016a). Greater levels of education about the benefits of R/S for Muslims, particularly Muslim women, could go a long way towards correcting this dynamic and lead to more respectful and empowering relationships in social work, and health care in general. Research on Muslims and Social Advocacy The presence of a power differential in research poses a problem for researchers that want to practice psychology in a liberatory way and work for social justice (MartínBaró, 1994). This research perhaps continued to place the women who participated further in the middle of the dialectic that Muslim women face on a daily basis between

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their faith and their precarious situation between the West and the East (Ebrahimji & Suratwala, 2011; Wadud, 2006). On the one hand, they have the commitment to their faith and identity as Muslims and their loyalty to the community of Muslims globally and in the U.S. On the other hand, they face the pressure and need to denounce fundamentalism and terrorism and acknowledge the problems with the way the religion is interpreted and practiced (Moghissi, 1999). This could, potentially, lead women to be unwilling to criticize or honestly state the problems that their R/S have created for them (Abdullah, 2015; Moghissi, 1999; Wadud, 2006). The women who participated in this study bravely walked the line between these two polarities. Limitations In spite of the important insights the participants shared into the importance of R/S for mental health, there are several significant limitations to this study. The fact that the sample was a convenience sample, the small size of the sample, and the small geographic area represented make these findings impossible to generalize to the larger Muslim community in the United States, or globally. However, the themes that emerged raise important questions for future research. Regarding research methodology, it will be useful to for researchers to move away from using local convenience samples, on which the majority of research on Muslims is based. Research that is more national and international, with a random sample including a comparison group would be very beneficial in helping the current research reach the next level of credibility and usefulness (Senzai & Bazian, 2010).

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Another of the limitations of the study were certain choices in the study design, including the choice of measures and the choice of specific protective factors as focal points. The instruments used, particularly the DUREL, were potentially not sensitive enough to distinguish differences between participants. Using better, more sensitive instruments will be important to advance understandings of the relationship between R/S and mental health. The choice of social support, self-esteem, and emotional health, prompted a split in the discussion between external expressions of religion involving community and identity and internal expressions of the religion involving belief, subjective experience, including thoughts and feelings. This combination was less effective potentially than splitting the inquiry into two separate pieces more clearly, one on personal and internal R/S and one on community and R/S. Another consideration that should be included in future research is the demographic of whether or not women are parents. Parenting, mothering, and childrearing prompted much discussion and comment and not collecting the data on how many participants were mothers was a weakness of the study. Particularly the fact that seven women emphasized care-giving and service and synonymous with their self-esteem shows how being a parent is intricately connected to R/S. How R/S impacts women as mothers, and their experience as Muslim mothers in community, as well as the connection between Muslim women’s internal relationship to the Divine and parenting merits further exploration. Given the exploratory interviewing strategy employed, aimed at drawing out a range of ideas and phenomena, the interviewer did not give study participants equal

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opportunity (or amount of time) to dwell on each question or theme. In this way, the frequency with which a theme or subtheme was endorsed provides an indication of but does not represent a clear prevalence rate for that theme or subtheme. However, using this approach, it was possible to reveal a range of important phenomena to be examined more closely and systematically in future studies. As an exploratory study the importance of its findings is in the contribution it makes to possible future directions for the now growing inquiry into how R/S operates as a protective factor for Muslim women. Future Research The current study demonstrates the potential value of further research on the protective effects of R/S on Muslim women’s mental health, and mental health in general. Further research could focus on how R/S promote mental health in a variety of areas, including contributing to beneficial social support, improving self-esteem through positive reinforcement of self-worth, and supporting emotional health. Studies focusing on women who practice Islam from a variety of backgrounds, educational levels, economic levels, and levels of acculturation are crucial for increasing our knowledge of how R/S buffers from risk and functions as a PF.

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APPENDIX A Sample Interview Questions for Individual Interviews Social support: - How do you feel that the Muslim community, including masjids and community centers, provides social support for you or other Muslim women you know? - How do you see you R/S as providing support in terms of peers and social relationships for you or other Muslim women you know? - Do you think that your contribution is valued by the Muslim community? - How do you feel your R/S supports family life for you or other Muslim women you know? Self Esteem: - What is self-esteem in your view? - How would you describe the influence of your religion and spirituality on your selfesteem on you and on Muslim women in the Bay area? Emotional health: - How does being a Muslim woman affect your emotional health or the emotional health of Muslim women you know? - Can you comment on and happiness, life satisfaction, meaning purpose for yourself and Muslim woman in general in the Bay Area? Other questions: Anything you would like to add? Is there a downside to R/S? Any suggestions?

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APPENDIX B Sample Interview Questions for Focus Groups Social support: - How do you feel that the Muslim community, including masjids and community centers, provides social support? - How do you see you R/S as providing support in terms of peers and social relationships? - Do you think that your contribution is valued by the Muslim community? - How do you feel your R/S supports family life? Self Esteem: - What is self-esteem in your view? - How would you describe the influence of your religion and spirituality on your selfesteem? Emotional health: - How does being a Muslim woman affect your emotional health or the emotional health? - Can you comment on and happiness, life satisfaction, meaning purpose? Other questions: Anything you would like to add? Is there a downside to your R/S? Any suggestions?