There is substantial evidence that older age is associated with numerous physical, social, psychological, and cultural challenges (Jeste et al., 2010). In general, there is a decline of physical strength, cognitive functioning, and quality of life (Diehr et al., 2013; Kirova et al., 2015). Older individuals commonly experience psychological problems, such as depression and anxiety (Hawkley et al., 2010). Recent studies on older Muslims and other CALD immigrants living in the West indicates that changes in roles and responsibilities can decrease social interaction and increase isolation and intergenerational conflicts (Liu et al., 2018; Salma & Salami, 2020; Treas & Batalova, 2009). Although women are generally recognized as a more vulnerable group, Muslim women may be at particular risk because of their immigration history, ethnicity, identity, and religion (Jasperse et al., 2012; Reitmanova & Gustafson, 2008).

Immigration is perceived as a difficult process as it can disrupt one’s values, culture, traditions, support, and social network (Khawaja et al., 2013). Compared to voluntary migration, the process is significantly more severe for those who are forcibly displaced and enter on a humanitarian visa (for a review, please see Bogic et al., 2015). As evidenced by Bogic and colleagues’ review (2015), humanitarian entrants can experience pre-migration trauma, which they have to manage along with a myriad of post-migration stressors. As a part of their post-migration resettlement and reconstruction of their lives, all newly arrived immigrants face varying levels of acculturative stress marked by the feelings of isolation, identity crises, loss, and confusion (Greenwood et al., 2017). There are acculturative stressors of becoming familiar with the new society and its values, morals, culture, and infrastructure (Sam & Berry, 2010). There is an ongoing negotiation between one’s original culture and norms and the adopted culture and norms.

Research indicates that acculturation can be particularly difficult for communities that are visibly different from the host society (Colic-Peisker, 2005). Muslim women can appear different from other women due to their religious clothing choices, which may increase the experience of discrimination in daily life (Ghumman & Ryan, 2013). Since the 9/11 terrorist attacks in the United States, representation of Muslims in the media and community attitudes toward this group have become more negative (Poynting & Perry, 2007). However, while the wearing of hijab is associated with greater reports of discrimination, it is also linked to better mental health and wellbeing (Jasperse et al., 2012). Culture and belief systems therefore play a fundamental role in the way that CALD communities display, experience, interpret, cope, and adapt to their environments and mental health experiences.

The role of culture must be considered in professional services designed to support mental health among Muslim women. CALD communities are less likely to access mental health services in Australia (Minas et al., 2013) and cultural factors play a meaningful role in this. There are numerous barriers to accessing professional mental health services for migrant and Muslim women, such as social taboos and stigma, lack of information about the available services, inability to navigate the local systems, lack of English proficiency, inappropriateness of the services, and practical difficulties that deter these women from seeking help (Kirmayer et al., 2011; Whitley et al., 2006). Therefore, it is important to explore culturally safe and sensitive approaches when working with older Muslim women in mental health settings.

There has been a renewed interest in developing and trialing psychological interventions for CALD populations settled in Western countries (Kalibatseva & Leong, 2014). Most of the emphasis has been on addressing PTSD and other severe mental health disorders among humanitarian entrants by using interventions such as Cognitive Behavior Therapy, Narrative Exposure Therapy, and Eye Movement Desensitization Processing (Kip et al., 2020). However, there has been a growing interest in developing and trialing group-based interventions to enhance the resilience and acculturation process of immigrants (Khawaja & Ramirez, 2019), as the use of expressive and creative therapies can provide an important medium for engagement with mental health services (Dieterich-Hartwell & Koch, 2017; Kalibatseva & Leong, 2014; Rowe et al., 2017). It is essential that such programs accommodate the unique issues and cultural and linguistic needs of CALD communities (Kirmayer et al., 2011).

The Tree of Life (TOL) program is grounded in Narrative theory and practice (Lock, 2016; White & Epston, 1990) that draws upon the metaphor of a tree as a symbol of life (Ncube, 2006). The therapist takes a position as a “partner” in a therapeutic dialogue and listens, taking a ‘not-knowing,’ respectful, and curious approach (White, 2007). Metaphors and narrative questions are used to encourage individuals to tell stories that are empowering, highlight personal and shared strengths, values, and dreams for the future (Denborough, 2012, 2018; Lock, 2016). A creative approach is adopted as participants draw their own tree during the intervention, with parts of the tree reflecting meaningful aspects of their life stories (for details of the intervention, see Vitale et al., 2019; Schweitzer et al., 2014). Instead of the problem-saturated approach of discussing past challenges, the facilitator encourages participants to explore their personal skills, knowledge, and cultural contexts in a safe setting (Denborough, 2008; Ncube, 2006; Randle‐Phillips et al., 2016). Therefore, this non-threatening and inclusive tool allows participants to visually externalize experiences and become aware of their resilience and positive attributes (Carlson, 1997). The group setting allows discussions among group members who play an active role as outside witnesses in validating each other’s personal skills, knowledge, and alternative narratives (German, 2013).

A review of the literature indicates that, in the last decade, the TOL program has been used within different cultural and societal contexts (Denborough, 2018). A few of these studies have used the TOL program with CALD individuals or groups resettled in a Western country. Iliopoulou (2009) found benefit for the TOL program in a community setting with former refugee women, who were living with human immunodeficiency virus (HIV). Schweitzer and colleagues (2014) adopted a case study format to describe its implementation with adolescents who were former Liberian refugees in Australia. Vitale and colleagues (2019) also used a case study format to study the benefits of the TOL program with African women resettled in United Kingdom, who were victims of war-related sexual abuse and living with HIV. These studies used interviews to determine how the TOL program helped participants recognize their strengths and gain an appreciation of positive aspects of their life. Commonly reported benefits were breaking down language and cultural barriers and helping individuals who have lived through trauma to re-author their narratives in ways that emphasize their strength and resilience. TOL’s social constructionist perspective allowed participants, who had undergone migration and resettlement in culturally distinct locations, to reconstruct their life stories to establish new social roles and responsibilities in new context (Bhugra & Becker, 2005).

There is now substantial evidence that older adults are at higher risk of experiencing psychological issues and social isolation (Treas & Batalova, 2009; Salma & Salami, 2020). Sociocultural factors can precipitate mental health concerns (Liu et al., 2018; Reitmanova & Gustafson, 2008), and these challenges have consequences for the older person’s wellbeing and quality of life (Bryant et al., 2012; Westerhof et al., 2011). Despite substantial research on the pre- and post-migration issues of immigrants (e.g., Bhugra & Becker, 2005), there is a scarcity of research on older Muslim women, or those who have been in Australia for longer periods of time. There is a lack of evidence-based culturally sensitive and appropriate interventions and programs for CALD populations. Considering that CALD populations may not seek help from professionals, it was important to explore if they would be receptive to a program if delivered at the community level. Though research on the TOL program is emerging, little is known about its effectiveness with CALD older adults (Gardner & Poole, 2009). Therefore, it was important to use a qualitative methodology, without any a priori hypotheses, to explore whether a group-based narrative approach such as the TOL highlights connectedness and resilience, while supporting an individual’s cultural values, beliefs, and religion, empowered life narratives, and promoted wellbeing (Harrison et al., 2017). To expand upon existing research, it was important to understand the effectiveness, feasibility, and acceptability of the TOL program with older Muslim women in a community setting that was easily accessible to them. As per Bowen and colleagues (2009), feasibility referred to the practical aspects of conducting the program, while acceptability referred to the participants’ responses and reactions to the TOL program and whether they perceive it as satisfying and helpful.

The current case study explored the effectiveness, feasibility, and acceptability of the group-based, manualized TOL program (Vromans et al., unpublished) with English-speaking older Muslim women from diverse backgrounds. The TOL program was positively received by the participants and perceived to be beneficial. The feasibility and acceptability of implementing the intervention with the targeted population in a community setting was supported.

In line with previous studies on the TOL program, the participants found the intervention a positive and beneficial experience (Vitale et al., 2019). Several Narrative Therapy principles appeared to enhance the therapeutic process (Schweitzer et al., 2014). The narrative questioning underpinned by Narrative Therapy (White, 2007) depicted through parts of the tree inspired the participants to reflect on their self and increased awareness of their skills, knowledge, and values (Lock, 2016). Consistent with previous studies (Denborough, 2012, 2018), the metaphor of storms assisted them to think about difficulties and the challenges in their own life associated with being an older female from a minority group (Jeste et al., 2010). In line with past research with older individuals, health issues, loneliness, and dependency on others were recognized as common problems (Diehr et al., 2013; Jasperse et al., 2012; Treas & Batalova, 2009). Consistent with literature, Islamophobia was recognized as a problem impacting intercultural relations (Khawaja & Khawaja, 2016). Nevertheless, participants were able to utilize the newly identified personal skills and strategies as a way of dealing with these present and future challenges (Denborough, 2008; Ncube, 2006; Randle-Phillips et al., 2016). Collectively, the participants identified religious and cultural beliefs as resources that could be applied to commonly experienced problems. Conversations about future hopes and wishes fostered optimism and warm feelings toward family members (Denborough, 2012, 2018). Social constructivist principles allowed them to construct new roles and responsibilities with refence to their context and histories (Bhugra & Becker, 2005).

From a Narrative Therapy perspective, conducting the program in a group format allowed for important therapeutic processes to occur. For example, it provided participants a safe place to interact with others and re-author their dominant narratives (German, 2013; van der Velden & Koops, 2005). Group members acted as the audience for each other and validated personal strengths and affirmed new narratives (Elderton et al., 2014; Randle‐Phillips et al., 2016). Participants’ strengthened narratives appeared to be centered around enhancing awareness of personal identity, empathy, and interconnectedness among people from different CALD backgrounds and different lived experiences. Several participants noted that the program inspired compassion and understanding of others and emphasized personal and collective strengths. These findings are consistent with previous trials of the TOL program with community samples of CALD and vulnerable persons (Iliopoulou, 2009).

The findings indicated that it is feasible to conduct the TOL program at a community level with older Muslim women from CALD backgrounds. It integrated well within the organization’s existing infrastructure. Organizational support, selecting an easily accessible venue, and scheduling the intervention on a day when women were already at the center maximized participation. The ethnic diversity of facilitators was purposeful and likely increased the feasibility of the intervention. Fidelity analyses indicated that the TOL manual was easy to follow by the facilitators. Participants were able to connect with the material and engaged well with the drawing process, shared their stories freely, listened to others, and provided support. They found the content suitable and appropriate, which supported the cultural sensitivity of the program (Denborough, 2018; Ncube, 2006).

Qualitative methods, such as the feedback forms, focus group discussion, and collecting their stories in sessions were practical, easy to implement, and provided useful information. These findings are consistent with previous studies that indicate experimental approaches are not a good fit with Narrative Therapy, as it is based on mechanisms and constructs not as easily operationalized (Etchison & Kleist, 2000; Vromans & Schweitzer, 2011). Given that the individuals’ socially constructed experiences, perspectives, and stories are of interest in narrative therapies (Carr, 1998; Freedman & Combs, 1996; White & Epston, 1990), textual and ethnographic methodologies focused on individuals’ narratives rather than clinical outcomes (Etchison & Kleist, 2000; Gardner & Poole, 2009).

Findings supported the acceptability of the TOL program with older Muslim women. They found the program enjoyable, interesting, promoting personal reflection on life, and reported greater social connection and cohesion within the group. It is important to note that similarities among the group members was a strength of this trial. Participants were all women, older in age, practiced Islam, largely from immigrant backgrounds, and spoke English. The shared identity, beliefs, and values helped them to develop group cohesiveness. Consistent with previous literature (Griner & Smith, 2006), homogeneity appeared to be an important factor to consider when the TOL program is implemented with a specific target group. The shared features strengthen a sense of safety and a sense of belongingness.

It is important to note that despite an overwhelming acceptability for the TOL program with older Muslim women from CALD background, the participants had a difficult time understanding what the program was about at the outset and this may be associated with the drop in numbers during the first two sessions. IWAA staff did not recognize the psychological nature of the activity and some continued to perceive it as a drawing class. Findings highlighted the importance of educating the participants and community organizations about the psychological nature of the program and the importance of confidentiality before commencing the intervention.