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Diversity and Equality in Health and Care (2021) 18(8): 425-429 2021 Insight Medical Publishing Group
Culture and Spirituality in the Process of Mental Health
and Recovery: Users and Providers Perspecves
Zoebia Islam1*, Fatemeh Rabiee2, Swaran P Singh3
1LOROS, Hospice Care for Leicester, Leicestershire and Rutland; Honorary Lecturer University of Leicester, UK
2Faculty of Health, Educaon and Life Sciences Birmingham City University (BCU), UK
3Head of Division in Department of Mental Health, Mental Health and Wellbeing Warwick Medical School, University of Warwick CV4
7AL; Honorary Consultant Psychiatrist Birmingham and Solihull Mental Health Foundaon Trust, UK
Introducon
Mental health patients with spiritual beliefs consider these to be
important, as do professional bodies [1-3]. However, standard
practice still focuses mainly on biomedical and social with no
consensus on whether services should address spiritual needs of
patients and how this should be done [4].
This paper is part of the ENRICH research program focusing
on socio-cultural determinants of ethnic dierences in pathways
to care in rst episode psychosis (FEP) [5]. The study site
Birmingham is one of UK’s most culturally and ethnically
diverse cities with signicant Black and Minority Ethnic (BME)
communities -British Pakistani (13.5%), British Indian (6.0%) and
Black Caribbean 4.4% (Birmingham City Council, n.d.). Here
we report the views of service users, carers, service providers
and spiritual care team representatives on the signicance of
spirituality, culture and religion on mental health recovery. We
aimed to explore the role of cultural and spiritual inuences in
how illness and recovery were experienced and understood.
Methodological Approach
Design
Using a topic guide, 11 focus groups were conducted as follows:
6 with service users (n=22), 3 with carers (n=11), 1 with health
professionals (n=9) and 1 with representatives of spiritual care
(n=8). Participants in each group were purposely included to
uncover any dierences and discrepancies or similarities that exist
between professionals delivering EI services and those receiving
these services. Spiritual attributions and cultural meaning of
distress, and faith-based help-seeking were specically explored
during focus group discussions with all participants.
Parcipants
The study was carried out in and with the support of Birmingham
and Solihull Mental Health Foundation Trust. All participants in
this study were recruited from EIS Birmingham.
Service users
The aim was to recruit participants who represent the ethnic mix
within each locality in the city. Hence, the inclusion criteria for
service users were to be from an ethnically diverse background
and a current or past EIS user. For detailed information about
the process of recruitment visit Islam et al 2015. Out of the 22
participants 12 were male and 10 were female (self-ascribed
ethnicity: 9 British Pakistani; 5 British Caribbean; 3 mixed White
and Black Caribbean; 3 Black British-African; 1 ‘other’; 1 British
Bangladeshi). They described their religious/spiritual aliation
as: Muslim (n=11); Christian (n=6); no faith (n=2) and ‘other’(3).
Carers
In total, 14 carers were recruited 3 of whom formed the pilot
study focus group (8 females; 3 males). The majority described
themselves as Black British-Caribbean (n = 5) and British
Pakistani (n = 3). Others included: 1 Black British-African; 1
mixed White and Black African; 1 White British.
Professionals
Nine clinicians (5 females; 4 males) were recruited - service
Abstract
Background: Spiritual beliefs are known to impact on mental
well-being and recovery, yet professionals and clinicians often
fail to explore user and carer perspectives on these.
Aims: Explore views of ethnically diverse service users,
carers, service providers including Early Intervention in
Psychosis service (EIS) professionals and spiritual care team
representatives on the signicance of spirituality, culture and
religion on mental health recovery.
Method: Eleven focus groups were conducted with service
users, carers, health professionals and representatives of spiritual
care.
Results: Thematic analysis uncovered three main themes on
service users’ mental health recovery: Shame and Creating a
Positive Sense of Self; Meeting Cultural, Spiritual, Religious
and Individual Needs; Spiritual and Religious Beliefs impact on
Well-being.
Clinical Implications: Healthcare professionals should
consider the impact of spirituality on services users’ mental
health recovery and well-being. Further training, guidance and
support are needed to increase professional competency.
Keywords: Culture; Healthcare; Mental health
426 Islam Z.
professionals (P) and spiritual care representatives (SC).
Results
Shame and creang a posive sense of self
Coming to terms with mental illness was a dicult process for all
service users. Spiritual care representatives stressed it challenged
the way they felt about themselves and how they related to others:
‘They [service users] internalise that shame, they can’t accept
being given a diagnosis because that seems to be the worst thing
possible, the most awful thing that could possibly happen to them
is that they could be told they’re mentally ill.’ (SC7).
Services users go through several emotional stages before coming
to terms with having a mental illness ‘recreating any new sense of
self’ or ‘positive self-identity’. In an attempt to maintain a positive
sense of self, in most cases there was a period of conscious and/or
unconscious denial of reality and resistance to accepting illness: ‘I
felt really suspicious of everyone and everything…I can’t explain
it, I’m still trying to comprehend what went wrong’ (SU22, British-
Pakistani, Male).
Some service users did not accept that they were unwell and
began normalizing symptoms and developed coping strategies/
explanations to maintain a sense of normality:
‘Yeah I just thought you know what I am who I am and I think
I control my own destiny and then God probably gave me this’
(SU20, Asian British-Pakistani, Male).
For others this was often followed by anger and grief: ‘But
I don’t want them [voices] to be there because I was never like
this. I can’t live hear some people talking’ (SU5, Black British-
African, Female).
Some carers also cited religious and cultural beliefs as explanations
for initial symptoms: ‘… this went on for a period of time where it
was getting worse for him… I started to think, as a black person
there was something wrong, I thought there’s a ghost in the place’
(C12, Black British-Caribbean, Female).
For the majority of service users, family and community members
encouraged faith-based help-seeking. This included visiting
multiple faith and spiritual healers. For some this practice proved
to be benecial and positive in bringing temporary solace for
both the service user and their family. Some service users from
Pakistani Muslim backgrounds continued to visit faith healers
even after coming to EIS. Some became victims of nancial
exploitation: ‘…he asked me for £500 … I actually went to the
cash point withdrew £500, …he gave me that egg anyway and
he goes when you gonna go somewhere far, throw it over your
shoulder and pray for what you want and don’t look back and
walk away and don’t go back there again…’ (SU13, British-
Pakistani, Female).
Service users highlighted that returning to a state of psycho-social
well-being was a dicult process. Becoming well often resulted
in the ‘rejection of the old self’ and ‘acceptance of the new self’ in
terms of, exercising personal agency by abstaining from behaviour
and practices such as drinking, smoking cannabis and spending
time with friends who were involved in such activities:
‘…as soon as we smoke weed or we have alcohol we’re not pure,
managers (n = 2), care coordinator (n = 1), senior social worker
(n = 1), community psychiatric nurses (n = 2), student nurse (n =
1), vocational worker (n = 1), and senior occupational therapist
(n = 1).
Spiritual care representaves
A total of 8 spiritual care representatives within BSMHFT were
recruited (3 females and 5 males) including the service manager
and chaplains, and volunteers from a multitude of diverse faith
backgrounds, including Christian chaplains, Muslim Imams, and
a humanist.
Ethical approval and informed consent
Ethical approval was granted by the Warwickshire Research
Ethics Committee; the study was also approved by the BSMHFT
research and development unit prior to approaching any potential
participants. All participants gave their informed consent before
the start of the focus group interview.
Data collecon and analysis
All focus groups were facilitated by ZI to ensure consistency
of approach, accompanied by a note-taker, who observed and
recorded the non-verbal interactions and documented the general
content of the discussion to aid analysis. De-brieng meetings
were held immediately after each focus group see Islam et al 2015
for further discussion [6].
All focus groups interviews were conducted in English with the
exception of one with service users in which an interpreter was
used to translate for one service user in Arabic. In the same focus
group the facilitator translated for another service user in Urdu.
Similarly in two carer’s focus groups the facilitator translated on
behalf of three carers in Urdu. All other stakeholder focus groups
were conducted in English. Each focus group lasted up to 90 min.
Each interview was audio taped and transcribed verbatim.
Analysis was conducted using a thematic approach to systematically
code, classify, and organize the focus group content into key
themes and sub-themes [7]. Drawing on Krueger and Casey’s [8]
framework analysis, each line of the transcript was numbered and
then printed and read by the facilitator and another member of the
research team to identify recurring concepts and categories [8].
Transcripts were then re-read by the facilitator to identify how
these concepts and categories formed the basis of a conceptual
thematic framework [7]. This framework was used to code
and classify data and then modied and rened throughout the
analysis to reect the content and issues expressed by respondents
across all focus groups. These coded categories were then sorted
into broader core themes based on similarity and content by the
facilitator and checked by FR.
For the purposes of this paper three key themes are discussed in
the context of the signicance of spirituality, culture and religion
on service users mental health recovery: Shame and Creating a
Positive Sense of Self; Meeting Cultural, Spiritual, Religious and
Individual Needs; Spiritual and Religious Beliefs impact on Well-
being.
Illustrative quotes are provided to aid transparency of
categorization and theme representation. To protect anonymity,
every participant in each focus group was given a letter code
and assigned a number: that is, service users (SU), carers (C),
427
Culture and Spirituality in the Process of Mental Health and Recovery: Users and Providers Perspecves
our bodies are not pure so we are prone to attack from evil forces’
(SU20, British-Pakistani, Male).
EI service sta, were considered to play a useful role in aiding
the creation of new social networks, through activities and events
arranged for service users this included art therapy, and social
media classes. These gave them the opportunity to network and
also enhance their CV.
Meeng cultural, spiritual, religious and individual needs
Spiritual care representatives raised concerns about EIS
professionals’ lack of knowledge and understanding of cultural
and spiritual needs of their clients:
‘We had … a Baptismal Service, …one of the service users
suddenly spoke in tongues, …The result of that was a bit of a
shock wave, and his Psychiatrist was thinking of upping his
medication… I was then, able to speak to that particular Consultant
Psychiatrist…I acquainted him to the fact that according to, the
Christian Scriptures, this was something that was happening in
the early Christian days, with all the early Christian leaders in the
beginning, and from time to time it happens. So… this Psychiatrist
said, “Oh, so I don’t need to up his medication?” I said, “No, …
this happens”’ (SC3).
‘Well, I think this is where it’s important that the Health Care
Professionals and the Psychiatrists or Consultants and the Nurses,
work with the Imams and try and understand Islamic perspective
on Mental Health…these are the things that one needs to look
at,… which would dierentiate from, someone, suddenly going
into this transit of speaking in tongues [or becoming mentally
unwell]’ (SC1).
Services users also acknowledged that EIS professionals did not
have sucient understanding about ethnically diverse cultural
beliefs. Those that continued to visit faith healers after coming to
EIS did not disclose this to EIS professionals for this reason:
‘We can’t blame them because their upbrining is dierent is like
westernized, they can’t understand if we talk about Jinn’s.’ (SU20,
British-Pakistani, Male)
The majority of professionals recognised that great variation
exists between and within cultures, reected in views held by
service users in terms of explanations of mental illness, and how
preferred treatment options dier. Hence these issues needed to be
considered on an individual basis in care plans. Professionals also
recognised that although some information around individuals’
beliefs and values was collated through the ‘Health and Social
Care assessment’, “this was underutilised” (P5 and P6), the main
reason being workload and time-constraints: ‘...in, my experience
I think we’re a bit behind in terms of understanding the depth of
other cultures, sort of dierent ways of looking at things and so I
think it’s tolerated more than embraced’ (P6).
There seemed to be a general consensus that there was not enough
cultural training given to EIS sta. Current diversity training
focuses on supercial dierences of appearance, clothes diet etc.
rather than spiritual beliefs. Instead EIS sta learnt about nuances
between dierent cultural groups through speaking to colleagues
from the same background as the service users as well as by
making mistakes and learning through experience: ‘… I’ve never
had a day of dedicated cultural awareness [other than the one day
Trust cultural and diversity training]…so I’ve learned through
blunders I’ve made. Through asking families, from colleagues’
(P6).
Spiritual and religious beliefs impact on well-being
There was consensus amongst some service users and carers that
a return to spiritual and or religious beliefs and practices was
potentially a sign of mental well-being: ‘right because before
he started this, entire he used to read the Bible but he put down
the Bible and then he started to get funny…’ (C4, Black British
Caribbean, Male). Decreased interest in religious practices or loss
of faith as well as undertaking behavior such as substance misuse
was viewed as potentially a symptom of psycho-social ill-health:
‘…You know he liked to pray to God and suddenly he didn’t want
to do it anymore, he didn’t want to go to church and then he would
just go for days and I wouldn’t know where he was….’(C14,
Black British-Caribbean, Female).
‘I just stopped reading the bible, I smoked too much weed, but
I’ve cut down on the weed now.’ (SU12, Mixed White and Black-
Caribbean, Male).
‘I had a big faith until I was 17, 18,...but then so much stu
happened in the family and then the devil just broke me down and
then it broke me down in such a way that he whispered on my ear
all this time you were good. All this time you did everything the
right way. What was it all for? What did you get rewarded?... I
was like f… this now watch; I’m going to do as much bad as I can’
(SU20, Asian British-Pakistani, Male).
Equally, becoming consumed in existential and religious issues
was also viewed as a potential sign of psycho-social ill-health:
‘Then he made up some notes of comparison, comparing
Christianity with Islam, with Paganism, idol worshipping and
he said that the area he ripped o the Bible, it’s the bad one …
Eventually I managed to, after begging him, managed to push the
door, with the help of someone who lived with me so that was
when I saw him, he ripped up his Bible and notes’ (C3, Black
British-African, Female).
‘But I just start to get all depressed thinking you know, you just
realise the truth say if I die you know what’s going to happen in
the grave and you know what’s going to happen in the after-life
and then you question yourself in the sense well I didn’t ask to be
born so what am I being tested for, what am I you know? There are
angels, there are Jinns, there’s God, there’s Devil. So what are we
then? Are we angels, are we Jinns? What are we human beings,
where are our souls going to go? (SU20, Asian British-Pakistani,
Male).
Hence, having spiritual/religious well-being did not automatically
equate to having psycho-social well-being. As one SC
representative stated if the ‘fruits of their spirituality…[are] being
useful and constructive then ne, if it’s being destructive and
obliviously, not getting anybody anywhere or being dicult for
people, then, harmful, then it’s not ne. Discernment it’s called’
(SC7).
Discussion
The signicance of spirituality, culture and religion on service user’s
mental health recovery is complex and varies for each individual.
Our ndings demonstrate that returning to a state of psycho-social
428 Islam Z.
well-being from a psychotic illness was a multifaceted process.
Becoming well often resulted in the ‘rejection of the old self’
and ‘acceptance of the new self’ in terms of, exercising personal
agency by abstaining from destructive behaviour. This echoes the
notion of “recovery capital”, highlighting the role of supportive
and inspiring new relationship with self and the signicant others
including health care professionals, family members, friends,
cultural and socio-environmental resources in empowerment and
recovery [9].
The concept of “social recovery” also has recently been argued
by Winsper and colleagues (2020) and their proposed logic
framework clearly indicate the importance of psychoeducational,
peer, social inclusion, and pro-recovery and mental health literacy
training and their outcomes at the service user, mental health
service, and general public level [10].
Activities and events arranged for service users by EIS sta was
described as key in the creation of new social networks and can be
linked to previous research which emphasizes the importance of
key coping strategies “proactive coping” [11]. Previous qualitative
research describes this ‘proactive coping’ as being part of the way
people with mental illness who show signicant improvement in
functioning overtime replace previous activities and routines with
those that provide a “sense of self” [12,13].
Our ndings also suggest that rather than simply reaching a point
of ‘true engulfment’; that is being consumed by their mental health
issues, service users are active agents and can exercise choice in
selecting and constructing their identities [14] and eventually
capable of constructing and recreating alternate identities to that
of a passive and powerless ‘patient identity’ [15]. The process of
moving towards psycho-social wellbeing and ‘creation of a new
sense of self’ is not based on an equal or rigid series of sequential
or uniformly timed steps, some stages may be revisited (i.e.
relapse) or not be experienced. There are numerous challenges
and opportunities for wellbeing and a ‘creation of a new sense of
self’ or ‘positive sense of self’ as illustrated in Figure 1.
Like Slade et al. [16] our ndings highlight that the user held
view of “personal recovery” is based on their beliefs. This
includes their spiritual and religious well-being and experiences
[16]. Hence it is vital that we explore the spirituality of service
users and its inuence in their personal recovery. Lack of respect
and understanding in relation to religious and spiritual beliefs
has been highlighted in previous studies [17, 18]. Data from
Koening [19], Department of Health [20], Rabiee and Smith [4]
also clearly suggest the therapeutic role of religion for people
with mental illness, and spiritual leaders as an important source
of contact and support for some BME communities. In line with
this notion Tokpah [21] argues that spirituality dimensions should
be addressed and considered as part of holistic patient care and
psychiatric nursing care. Yet standard clinical practice still focuses
mainly on biomedical needs and there is no consensus on whether
mental health services should address spiritual needs of patients
and how this should be done [4, 22]. It is clearly evident from our
data that professionals need to consider the impact of spirituality
on services users’ mental health recovery and wellbeing. However
in order to do this they require further training, as well mentoring,
guidance and support from Spiritual care Advisors and experienced
colleagues.
Funding informaon
Programme Grants for Applied Research, Grant/Award Number:
RP-PG-0606-1151.
Declaraon of conicng interests
Author C is part funded by NIHR Applied Research Collaboration,
West Midlands (ARC-WM). Authors A and B have no conict of
interest. The views expressed in this publication are those of the
author(s) and not necessarily those of the NIHR or the Department
of Health and Social Care.
Grief/Resistance
Internalising s�gma
Relapse
(Poten�al behaviour includes:
non-compliance with treatment
and/or substance misuse)
Spiritual/Religious
Ill-health
Spiritual/Religious
Well-being
Psycho-
Social
Ill-health
Acceptance
Recrea�ng new self
(Poten�al behaviour includes:
compliance with treatment
and/or reduced/no substance
misuse)
Poten�ally
Moving
towards
Psycho-
social well-
being
Psycho-Social
Well-being
Poten�ally
Moving
towards
Psycho-social
well-being
Figure 1: Challenges and Opportunities for wellbeing and a ‘creation of a new sense of self’ or ‘positive sense of self’.
429
Culture and Spirituality in the Process of Mental Health and Recovery: Users and Providers Perspecves
Acknowledgements
The ENRICH team include: Prof. Swaran Singh, Dr. Zoebia
Islam, Dr. Luke Brown, Dr. Rubina Jasani, Dr. Ruchika Gajwani,
Ms. Shabana Akhtar, Ms. Charlene Jones, Ms. Madeline Parkes,
Mr. Nathan Worthington-Williams, Dr. Helen Parsons, Prof.
Fatemeh Rabiee, Prof. Max Birchwood, Prof. Helen Lester, Dr.
Hannah Bradby. Our thanks to all the researchers that contributed
to ENRICH study 3, especially Ms. Shabana Akhtar, Ms.
Gagandeep Chohan, Ms. Marta Wanat and Dr. Aman Durrani.
We are also grateful to all Clinicians, Commissioners, Voluntary
and Community Organisation representatives, Spiritual Care
representatives, patients and carers and members of the steering
group who generously oered their time and support to the study.
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Address of Correspondence: Zoebia Islam, LOROS, The
Leicestershire and Rutland Hospice, Groby Road, Leicester, LE3
9QE, UK, Tel: +447384817722; E-mail: ZoebiaIslam@loros.co.uk
Submitted: August 06, 2021; Accepted: August 19, 2021;
Published: August 26, 2021
