The Imam’s Role in Meeting the Counseling Needs of Muslim Communities in the United States Osman M. Ali, M.D. Glen Milstein, Ph.D. Peter M. Marzuk, M.D.

Objective: Muslims are one of the most rapidly growing minority groups that clergy often serve as first-line in the United States and have experienced increased stress since Sep- mental health care providers and facil- tember 11, 2001. The purpose of this study was to elucidate the roles of itators to help communities gain ac- imams, Islamic clergy, in meeting the counseling needs of their com- cess to a larger network of mental munities. Methods: An anonymous self-report questionnaire was mailed health services (5–8), particularly in to 730 mosques across the United States. Results: Sixty-two responses minority communities (9). A recent were received from a diverse group of imams, few of whom had re- analysis of data from the National Co- ceived formal counseling training. Imams reported that their congre- morbidity Survey found that clergy gants came to them most often for religious or spiritual guidance and continue to provide more mental relationship or marital concerns. Imams reported that since September health care than psychiatrists, includ- 11, 2001, there has been an increased need to counsel persons for dis- ing treatment of people with serious crimination. An increased need to counsel persons who were discrimi- mental illnesses (10). nated against was reported by all imams with congregations in which a Previous research on the role of majority are Arab American, 60 percent of imams with congregations in clergy members in meeting psychi- which a majority are South Asian American, and 50 percent of imams atric counseling needs has been con- with congregations in which a majority are African American. Conclu- ducted with Christian and Jewish sions: Although imams have little formal training in counseling, they are clergy members (11–15) but not asked to help congregants who come to them with mental health and so- with imams, who constitute clergy of cial service issues. Imams need more support from mental health pro- the third Abrahamic faith, Islam. As fessionals to fulfill a potentially vital role in improving access to servic- with Christian and Jewish clergy es for minority Muslim communities in which there currently appear to members, the traditional roles of be unmet psychosocial needs. (Psychiatric Services 56:202–205, 2005) imams are to lead prayers, deliver sermons, conduct religious cere- monies, and provide religious and he U.S. Surgeon General groups in the United States and are spiritual guidance (16). found a significant need for an ethnically diverse group (3). Mus- Muslims consider Islam to be cen- Tmental health providers to ad- lims have faced increased discrimina- tral to their way of life and place great dress stigma, discrimination, distrust, tion as a minority group after the value on the integrity and functioning and differences in culture-specific ex- events of September 11, 2001, and of the family. Thus, when Muslims periences when they respond to the their aftermath (4). It is not well have marital or family problems, they mental health problems of persons known whether the need for mental might consult with their imams. In from minority communities (1,2). health services has increased among order to help community members Muslims, with an estimated popula- Muslims or what resources are avail- with their problems, the religious tion of six to nine million, are one of able to meet those needs. leaders would be expected to refer- the most rapidly growing minority Five decades of research have found ence and interpret The Qur’an (sometimes transliterated as The Ko- ran) and The Hadith, which are Holy Dr. Ali is affiliated with the department of psychiatry at Bellevue Hospital, New York Uni- Scriptures of Islam. The Mosque in versity Medical Center, 462 First Avenue, 20 West 1, New York, New York 10016 (e-mail, America study, which described the [email protected]). Dr. Milstein is with the department of psychology at The City Col- structure and functioning of 416 lege of The City University of New York in New York City. Dr. Marzuk is with the de- mosques and the roles of the leaders partment of psychiatry at Weill Medical College of Cornell University in New York City. of these mosques, found that 74 per-

202 PSYCHIATRIC SERVICES o http://ps.psychiatryonline.org o February 2005 Vol. 56 No. 2 cent of the mosques provided mari- Table 1 tal and family counseling services di- Comparison of demographic characteristics of imams from study sample with rectly to their congregants (17). imams from the sample from the Mosque in America studya However, it is not known if imams are well prepared to identify, treat, Sample Sample from the and, when necessary, refer congre- (N=62) Mosque in America study (N=416)b gants with emotional, behavioral, or Total psychosocial problems to psychiatric Characteristics N N % N % services. We sought to elucidate the role of Region of the United States 58 imams in meeting the counseling Northeast 15 26 125 30 South 17 29 108 26 needs of their communities in the Midwest 11 19 121 29 United States. In this article we sum- West 15 26 62 15 marize the imams’ reports of the na- Community setting 56 ture and extent of the counseling Rural or town 17 30 87 21 needs of their respective congrega- Suburb or city neighborhood 28 50 245 59 tions and changes in these needs Inner city 11 20 87 21 since September 11, 2001. We also Year mosque established 57 report imams’ current and past coun- 2001 to 2003 2 4 — seling experiences and training. 1990 to 2000 24 42 125 30 1980 to 1989 18 32 133 32 Methods 1970 to 1979 12 21 104 25 Before 1970 1 2 54 13 We conducted a nationwide cross- Imam’s age (mean±SD years) 54 49±12 48c sectional survey of imams from Years at current mosque (mean±SD) 57 8±7 10c mosques throughout the United a States by using the directory in The Some of the percentages total more than 100 percent because of rounding and because some imams considered themselves to fall into more than one category. North American Muslim Resource b N=416 for all variables Guide, which contains the addresses c SDs were not reported. of 1,118 mosques (3). In February 2003 we mailed 450 questionnaires to imams of mosques that were randomly selected from the Results seling training experiences, 13 per- guide. In April 2003, because we be- Sixty-two of 730 questionnaires were cent (seven of 56 respondents) re- gan receiving more undeliverable returned (return rate of 8 percent). ported having had a formal clinical questionnaires than completed ones, Table 1 compares participants of this pastoral education, 21 percent (12 of we mailed another 314 questionnaires, study with those in the Mosque in 56 respondents) reported having tak- this time using only the remaining ad- America study, which had a return en a course on counseling given by an dresses that also were listed in the Ver- rate of 66 percent. Gender was not Islamic organization, and 25 percent izon Superpages’ online directory. A asked because imams, by definition, (14 of 56 respondents) reported hav- total of 730 questionnaires were not are male. Ninety-one percent of ing consulted with or worked under returned as undeliverable. imams (50 of 55 respondents who an- the supervision of a mental health Each mailing was written in Eng- swered this question) reported that professional. lish and included a cover letter ad- their mosques’ Islamic affiliation was Fifty percent of imams (28 of 56 re- dressed to the imam that described Sunni, and 53 percent (30 of 57 re- spondents) reported spending one to the study and assured anonymity, an spondents) reported that their com- five hours each week in counseling endorsement letter from an imam of munities had more than 100 families. activities, and 30 percent (17 of 56 re- a large Midwestern community, a Table 2 summarizes the ethnicities of spondents) reported spending six to stamped self-addressed envelope, the imams, the ethnic composition of ten hours each week. Five percent and a 79-item questionnaire, which their communities, and the number (three of 56 respondents) reported was developed by the authors and of communities in which more than that they did not spend any time adapted from previous work (14). 50 percent of the members are of a counseling. The proportion of the We sent reminder postcards to all single ethnicity. imam’s workweek spent in counseling the mosques one month after the No imams reported having a de- activities ranged from 0 to 80 percent, first wave of mailings and did not gree in psychiatry (0 of 55 respon- with a mean±SD of 17±17 percent. provide any monetary incentives. dents). Five percent reported having As shown in Table 3, the two most fre- The institutional review board of the a degree in psychology (three of 55 quently reported reasons for which Weill Medical College of Cornell respondents), 9 percent in social work congregants sought counseling “very University approved the research (five of 55 respondents), and 7 per- often” were religious or spiritual protocol and method of informed cent in counseling (four of 55 respon- guidance (24 of 57 respondents, or 42 consent. dents). Given a list of possible coun- percent) and relationship or marital

PSYCHIATRIC SERVICES o http://ps.psychiatryonline.org o February 2005 Vol. 56 No. 2 203 Table 2 South Asian American, and 50 per- cent of imams (five of ten respon- Ethnicities of imams and their congregationsa dents) with congregations in which a Imam’s majority are African American. ethnicityb Congregations’ N mosques ethnicity with >50% Discussion c Characteristic N % (mean %) single ethnicity Our principal finding is that imams Arab, Middle Eastern, are asked to address counseling issues Iranian, and Turkish 18 33 27 7 in their communities that reach be- South Asian 17 31 36 17 yond religious and spiritual concerns African American, Sub- and include family problems, social Saharan, and Caribbean 11 20 22 10 needs, and psychiatric symptoms. We Caucasian and European 1 2 4 1 East Asian 1 2 3 __ also found that there has been an in- Hispanic and Latino 0 0 1 __ crease in the need for counseling for Other 7 13 5 2 issues of discrimination since Sep- tember 11, 2001, particularly in Arab- a A total of 55 imams responded to the questions about the imam’s ethnicity and the composition of American communities. To our the congregations’ ethnicity. A total of 32 imams responded to the question about the number of mosques in which more than 50 percent of the members are of a single ethnicity. knowledge this study is the first to de- b This total exceeds 100 percent because some imams considered themselves to fall into more than scribe and quantify the multiple men- one category. tal health counseling roles of Muslim c The total is less than 100 percent because estimates of some individual imams did not total 100 clergy across the United States. percent. Imams are less likely than other clergy to have formal comprehensive counseling training that might help concerns (15 of 55 respondents, or 27 nancial concerns, and 51 percent (27 them to effectively address their com- percent). of 53 respondents) for anxiety. munities’ multidimensional needs. There were four concerns for Imams’ reports of increased need to The ethnic diversity of Muslim com- which a majority of imams reported counsel for actual discrimination munities suggests the need for mental an increase in congregants’ need for since September 11, 2001, differed health professionals who have partic- counseling after September 11, according to their mosques’ ethnic ular sensitivity to congregants’ indi- 2001: 68 percent (36 of 53 respon- majority: 100 percent of imams (sev- vidual cultural and religious back- dents) saw an increase in need for en of seven respondents) with con- grounds. counseling for fears of discrimina- gregations in which a majority are The rate of return of 8 percent rais- tion, 62 percent (33 of 53 respon- Arab American, 60 percent of imams es a number of considerations. Many dents) for actual discrimination, 62 (nine of 15 respondents) with con- mosques may not have had an appro- percent (32 of 52 respondents) for fi- gregations in which a majority are priate individual to complete the sur-

Table 3 Reasons for which congregants currently come to imams for counselinga

Never Sometimes Often Very often Mean Reason N scoreb SD N % N % N % N %

Religious or spiritual guidance 57 3.12 .87 1 2 15 26 17 30 24 42 Relationship or marital concerns 55 2.82 .9 3 5 19 35 18 33 15 27 Parent-child concerns 56 2.59 .85 3 5 27 48 16 29 10 18 Death or dying 56 2.45 .95 8 14 25 45 13 23 10 18 Financial or employment difficulties 54 2.41 .92 8 15 24 44 14 26 8 15 Doubts or weakness in faith 56 2.38 .82 6 11 29 52 15 27 6 11 Depression or sadness 55 2.24 .79 7 13 33 60 10 18 5 9 Fear of being discriminated against 57 2.12 .87 12 21 32 56 7 12 6 11 Having been discriminated against 56 2.11 .8 11 20 32 57 9 16 4 7 Physical or medical symptoms 55 1.93 .86 18 33 27 49 6 11 4 7 Anxiety or nervousness 56 1.86 .72 17 30 32 57 5 9 2 4 Sexual concerns 56 1.73 .88 28 50 18 32 7 13 3 5 Odd thoughts or actions 55 1.69 .69 23 42 27 49 4 7 1 2 Problems with drugs or alcohol 56 1.5 .71 33 59 20 36 1 2 2 4 Suicidal thoughts 56 1.21 .62 48 86 6 11 0 0 2 4 a Some of the percentages total more than 100 percent because of rounding. b As measured by a Likert scale: 1, never; 2, sometimes; 3, often; and 4, very often.

204 PSYCHIATRIC SERVICES o http://ps.psychiatryonline.org o February 2005 Vol. 56 No. 2 vey, because 19 percent of mosques improving access to appropriate men- 8. Schindler F, Berren MR, Hannah MT, et al: How the public perceives psychiatrists, psy- do not have imams (17). The compre - tal health and social services for mi- chologists, nonpsychiatric physicians, and hensive questionnaire—which in- nority Muslim communities where members of the clergy. Professional Psy- cluded 79-items, a vignette, multiple there currently appear to be unmet chology: Research and Practice 18:371– Likert scales, and open-ended ques- psychosocial needs. o 376, 1987 tions—may have been a barrier to 9. Young JL, Griffith EEH, Williams DR: The Acknowledgments integral role of pastoral counseling by imams whose primary language is not African-American clergy in community English and to imams who are over- Funding and resources were provided by mental health. Psychiatric Services 54:688– burdened with obligations. Other the Payne Whitney Clinic psychiatry resi- 692, 2003 dency training program of the depart- imams may have thought that a sur- 10. Wang PS, Berglund PA, Kessler RC: Pat- ment of psychiatry at New York–Presby- vey about mental health issues was terns and correlates of contacting clergy for terian Hospital, Weill Medical College of mental disorders in the United States. not relevant to their role as a religious Cornell University. Dr. Milstein’s work Health Services Research 38:647–673, leader. was supported by a grant from the social 2003 The sociopolitical climate in the sciences division of The City College of The City University of New York. 11. Domino G: Clergy’s knowledge of psy- United States also could have been a chopathology. Journal of Psychology and significant factor in lowering the re - Theology 18:32–39, 1990 References sponse rate. During the time that we 12. Weaver AJ: Has there been a failure to pre- conducted our survey, the United 1. Mental Health: A Report of the Surgeon pare and support parish-based clergy in General. Rockville, Md, Department of their role as frontline community mental States had embarked on a war against Health and Human Services, US Public health workers? A review. Journal of Pas- a Muslim country, Iraq, and the gov- Health Service, Office of the Surgeon Gen- toral Care 49:129–147, 1995 eral, 1999 ernment had enhanced its surveil- 13. Weaver AJ, Koenig HG, Ochberg FM: lance of imams’ sermons and 2. Mental Health Culture, Race, and Ethnici- Posttraumatic stress, mental health profes- mosques’ activities. Some imams ex- ty: A Supplement to Mental Health: A Re- sionals, and the clergy: a need for collabo- port of the Surgeon General. Rockville, ration, training, and research. Journal of pressed their concern about our in- Md, Center for Mental Health Services, Traumatic Stress 9:847–855, 1996 tentions for conducting this survey. 2001 14. Milstein G, Midlarsky E, Link BG, et al: Such concern may have also reduced 3. Nimer M: The North American Muslim Assessing problems with religious content: our return rate. Resource Guide: Muslim Community Life a comparison of rabbis and psychologists. Despite the low return rate of this in the United States and Canada. New Journal of Nervous and Mental Disease York, Routledge, 2002 anonymous survey, it elicited re- 188:608–615, 2000 sponses from a group of imams who 4. Christie-Smith D, von Brook P: Highlights 15. McMinn MR, Aikins DC, Lish RA: Basic of the 2001 Institute on Psychiatric Ser- and advanced competence in collaborating are ethnically, professionally, and reli- vices. Psychiatric Services 53:32–36, 2002 with clergy. Professional Psychology: Re- giously diverse and who lead a variety search and Practice 34:197–202, 2003 5. Veroff J, Kulka R, Douvan E: Mental of Muslim congregations throughout Health in America: Patterns of Help-Seek- 16. Haddad YY, Lummis AT: Islamic Values in the United States, similar to the larg - ing from 1957–1976. New York, Basic the United States: A Comparative Study. er Mosque in America study, which Books, 1981 New York, Oxford University Press, 1987 was conducted before September 11, 6. Larson DB, Hohmann AA, Kessler LG, et 17. Bagby I, Perl P, Foehle B: The Mosque in 2001. al: The couch and the cloth: the need for America: A National Portrait: A Report linkage. Hospital and Community Psychia- From the Mosque Study Project. Washing- try 39:1064–1069, 1988 ton, DC, Council on American-Islamic Re- Conclusions lations, 2001 7. Piedmont EB: Referrals and reciprocity: Further studies are required to con- psychiatrists, general practitioners, and 18. Milstein G: Clergy and psychiatrists: oppor- firm our results and to describe the clergymen. Journal of Health and Social tunities for expert dialogue. Psychiatric degree to which imams use commu- Behavior 9:29–41, 1968 Times 20:36–39, 2003 nity mental health resources. Also, fu- ture surveys to comprehensively as- sess needs should elicit the perspec- tives of Muslim congregants, espe- cially women and persons who come from different cultures than their Correction imams, to ascertain if their counseling needs are being met. We recognize In the brief report “Reactions of Staff Members to the Re- the need to foster communication location of a Psychiatric Department to a New Building” and trust between Muslim religious by Kagan et al., in the June 2004 issue (pages 717–719), leaders and mental health profession- there is an alignment error in Table 1 (page 718). The val- als to improve access to religiously ues in the last row of the table should appear one place to and culturally appropriate psychiatric the left. services. As mental health profession- als have done with other clergy (15, 18), they could collaborate with imams through outreach services to help fulfill a potentially vital role in

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