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What, then, does the mental health professional, pastoral counsellor or clergy do with this information? The suggestions we make in this chapter are based on the evidence from research, clinical experience, and common sense. We begin this chapter with a series of three case vignettes to illustrate the kinds of clinical encounters that mental health professionals and clergy are likely to have when seeking to help Muslim clients.
Case Vignette #1
Miss A is a 36 year old single woman from Saudi Arabia with severe anxiety who presents for outpatient treatment. A brief spiritual history reveals that she is Muslim and from a very religious family. Although she has always been somewhat anxious, it appears that her anxiety worsened significantly after she had a conversation with one of her girlfriends about religious matters. Miss A was somewhat reluctant to talk about this with the therapist, a non-Muslim, but with gentle encouragement by the therapist, she began to describe that conversation. Her girlfriend had asked Miss A the following question. If Miss A was to die suddenly (from a car accident or medical problem), did she think she had done enough good deeds to outweigh her bad deeds on the Day of Judgement. This got her thinking, and in particular, got her to worrying. She had slacked off on her daily prayer, was not giving alms, had been to several parties that year where she consumed alcohol, and had given in to her boyfriend and had sex with him last month. Soon after the conversation, Miss A became convinced that her bad deeds probably outweighed her good deeds, and that Judgement Day would be a bad time for her. This worry began to consumer her, interfering with sleep and even work. The therapist suggested a course of weekly cognitive-behavioural therapy to address her anxiety, and suggested breathing and relaxation exercises that she could practice at home.
Progress was slow. During one of the CBT sessions, the therapist (who has existence experience treating Muslims patients and was knowledgeable about Islam) asked Miss A’s permission to utilise her religious beliefs to help with the therapy. Desperate for relief, Miss A readily agreed. The therapist asked her to come up with a list of “good deeds” that she might engage in between sessions, and suggested she bring in an English version of the Qur’an for their next session. On the following week, Miss A came to therapy with a list of deeds as requested and a copy of the Qur’an. The therapist asked her to turn to 2:277 and read it out loud: “Those who believe, do good deeds, keep up the prayer, and pay the prescribed alms will have their reward with their Lord; no fear for them…” The therapist then asked her to turn to 6:160 and read that verse: “Whoever has done a good deed will have it 10 times to his credit, but whoever has done a bad deed will be repaid only with its equivalent…” The therapist asked her to explain what these passages meant to her. After a brief discussion, Miss A let out a sigh, and said that she would try to do some good deeds before the next session. When the therapist saw her the following week, Miss A reported having started praying again and giving alms, and indicated that her anxiety symptoms were much better.
Case Vignette #2.
Mrs. T is a 50 year old successful and determined business woman with a strong personality and clear vision. Several years ago her nephrologist diagnosed her with polycystic kidney disease, and inherited disease associated with kidney failure and eventually requiring haemodialysis. She knew everything about her kidney problems and that it would only be a matter of time before she would have to go onto dialysis or die from her disease. However, she did not allow her condition to stop her career, professional development or social relationships. Eventually, the day came when her kidneys failed, dialysis was required, and finally a kidney transplant became necessary. Even after this, however, she continued to pursue her career and came back stronger than ever. Mrs. T is a deeply religious woman, although when you first meet her, you would think that she is anything but religious. During her battle with kidney disease, however, she said her relationship with Allah became very close. A few years after she received her kidney transplant, the new kidney gradually began to fail – and this time it was more difficult than it had been the first time. She became depressed and started having physical symptoms of kidney failure, including poor concentration that forced her to stop working.
The combination of depression and kidney failure caused her nephrologist to admit her to the hospital where she stayed for three months. Her body weakened and she became more and more fragile to the point where should could barely talk due to her depression. The nephrologist was not optimistic about her recovery. He thought for sure that the illness would end her career and business. Therefore, he referred her to a therapist to help her with the depression. After several weeks of supportive therapy with little progress, and knowing from their initial session (when a spiritual history was taken) that Mrs. T was religious, the therapist asked her if she would be willing to allow the therapist to utilise her religious beliefs in the therapy. She agreed. The therapist inquired further about what beliefs and practices were particularly important to her. She indicated that prayer and reading from the Qur’an had been especially comforting to her in the past, but had stopped doing these regularly during the past several months. So, the therapist encouraged her to restart these religious practices focusing them on the specific problems she was dealing with. The therapist suggested that she recite in Arabic a chapter from the Qur’an, the Surta-al-Ikhlas (“Say, “He is Allah, [who is] One, Allah, the Eternal Refuge. He neither begets nor is born. Nor is there to Him any equivalent”” (112:1-4). This, the therapist told her, was what the Prophet Muhammad would recite when he became ill (Sahih al-Bukhari, volume 7, book 71:644). As she began to pray and recite from the Qur’an regularly, she found that her religious faith began to deepen and her feelings of being overwhelmed began to lessen. Her therapist encouraged these religious practices and since the therapist was also Muslim, even engaged in prayer with her on occasion during therapy sessions (when Mrs. T requested her to do this).
After several months of therapy, Mrs. T travelled to another Arabic country where she had close relatives who invited her to stay with them so that they could care for her. However, she frequently travelled back and forth to her home in Riyadh and remained in contact with the therapist. when her nephrologist saw her in his when she returned for a visit, he discovered to his surprise that her depression had dramatically improved. She appeared charming, happy, and was even back to work part-time. Though her body remained weak, her spirit was strong. In talking with her about how she was able to cope with all this, she told the nephrologist that it was her trust in Allah (supported and encouraged by her therapist) that was getting her through these extraordinarily difficult times and helped her to never give up or lose hope.
Case Vignette #3.
Mr. M is in his late 30s and vice president of a large company, a position to which he had quickly advanced. He had a strong personality, was persistent, and was dedicated to his work. He also had a large family and many friends with good relationships. His goal was to become a community leader at a young age, and everything was on track for that to happen, as he had real charisma. Then one day he was out in the field checking on a company project. While travelling to a job site, his driver got into a catastrophic car accident. Mr. M was immediately taken to the nearest hospital in a coma. The doctors told his family that he would likely die from his injuries. Although he survived, he was left with a broken neck and quadriplegia, and could not move his arms or legs or eat without assistance. The doctors told him that he would likely be bed-ridden for the rest of his life.
Few situations are more difficult to cope with in life than the one that Mr. M found himself in. Initially, he was overwhelmed and fell into a deep depression. His physician referred him to a counsellor to help him to adjust to his severe disability. The therapist took a careful spiritual history during his initial evaluation. Realising that he had strong religious beliefs, he asked Mr. M if he would like to try religious form of therapy, which he readily agreed to. The therapist then implemented a religiously-integrated version of Islamic cognitive behavioural therapy (CBT), a form of psychotherapy firmly grounded on the Qur’an.
After 10 weekly sessions that involved daily homework practices including meditating on passages in the Qur’an, Mr. M gradually learned to cope with his disability and his depression began to improve. As his motivation returned, he learned to do many things using his wheel-chair. Soon, Mr. M has resumed his regular trips to Mecca (Hajj and Umrah), which he made three times per year. As his mood improved, he began to attend social functions again, such as weddings, funerals, and community get-togethers. Despite his disability, his religious faith (strengthened by the therapy) made him a bright light at these social events since he had not lost his charisma and was still very charming with a deep sincere smile. In addition, because of his position as a businessman in the community, Mr. M began to help resolve disputes between different people in the community. He would even contribute financially from his own funds to reach a peace accord between feuding parties. In spite of being in a wheel-chair, he would regularly go to the mosque to pray and worship.
When talking with Mr. M, his therapist – whom he would continue to see periodically- noticed that he would frequently talk about his close relationship with Allah and how much he loved him. It was from this relationship, Mr. M maintained, that he derived his value as a person. In spite of his severe disability, Mr. M said that he felt good about himself because his self-esteem was grounded on this relationship. He believed that Allah had a purpose for his life, and that purpose is what kept his morale high and prevented him from feeling low or inferior to others. Although realistic about his disability, Mr. M shared with his therapist one day that since his accident he had discovered that life had more purpose than ever before. He believed that it was his duty to do as much good as he could, since he had many things that others did not have, including knowledge, money, and respect. He said, “I can cope with anything and any problem in my life if I am persistent and stay close to Allah and in Allah’s will.”
Response to Vignettes
These cases raise many questions. Should therapists depart from the standard secular approach to treatment by bringing religion into the therapy? In Case #1, despite little progress towards improvement, should the therapist have continued to encourage deep breathing and progressive relaxation, instruct her to be mindful and present centred, prescribe pleasant behaviours to distract her from her religious ruminations, and challenge her dysfunctional cognitions causing her anxiety (her religious belief)? Those methods were not working in this case. This raises a dilemma that is not easily resolved, and may depend on the particular client and the specific issue that the client is struggling with. Rather than improve Miss A’s anxiety, bringing religion into the therapy may have increased it – particularly in the long-term as her so called “dysfunctional” religious beliefs became more central to her life and continued to influence her emotional state in various ways. But are these religious beliefs really dysfunctional for this client from a deeply religious family whose support network is primarily her religious community? Might her resumption of doing “good deeds” over the long term actually led to a fuller, higher quality of life for Miss A?
What about Cases #2 and #3? In each instance, the therapist took a spiritual history and with permission, began to utilise the client’s religious beliefs in therapy to help them to cope with the severe stressors that were driving their emotional distress. In Case #2, the therapist even participated with the client in a religious practice, seemingly going beyond the boundary of the therapist-client relationship. In most cases, the therapist should be supportive and encouraging, but remain neutral. However, since the patient had requested to pray with the therapist, they were of the same religion, and the client was coping with a specific situational stressor, there may be instances when such boundaries may be relaxed.
In Case #3, the therapist decided that religious CBT might be particularly effective in helping this client deal with his devastating disability. Unfortunately, there are no long-term follow-up studies of religiously-integrated psychotherapies in Muslims (beyond about three months) that incorporate religious beliefs into the treatment of emotional disorder. Nevertheless, based on the existing research reviewed above, randomised clinical trials in Muslims have at least in the short-term documented substantial benefits from such an approach.
The following recommendations are based on the evidence from systematic research identified earlier, our combined 50+ years of clinical experience treating Muslim patients, and just plain good common sense.
1. Take a Spiritual History
Whether or not a therapist utilises a Muslim client’s religious beliefs in therapy, a spiritual history should always be taken early in the treatment (on initial evaluation, or soon afterward). The purpose of the spiritual history is to identify the specific religious beliefs of the client, the importance of those beliefs to the client, the extent to which beliefs and practices are adhered to, the religious beliefs and religiosity of the client’s family of origin, and the religious beliefs and religiosity of the client’s support system. Beliefs about the Qur’an and to what extent it is authoritative in the client’s life should also be explored. Finally, both good and bad experiences with religion across the client’s life course should be asked about. This information will be invaluable in deciding on the treatment approach and in providing treatment that meets the minimum standard of showing respect for clients’ personal beliefs and values (as required by most credentialing organisations). Mental health professionals should assume nothing in this regard, but rather have each client educate them about what role religion plays in their life, in helping them deal with their illness, or in initiating, worsening or maintaining the illness.
If the therapist is uncomfortable asking about religious issues (i.e., taking a spiritual history) then such resistance must be overcome with training and practice. Learning about the role that religion plays in the Muslim client’s illness, particularly when it influences just about everything in that person’s psychological, behavioural, social and work life, is quickly becoming the standard of care. Again, this does not mean the therapist needs to integrate those religious beliefs into the treatment, but knowing about them will be essential in providing therapy that is sensitive to and respectful of those beliefs.
2. Provide a Safe Place
Provide an open and safe place where clients can talk freely about their religious faith, good or bad, without judgment. Maintain a respectful, interested, and receptive attitude at all times with regard to the client’s Islamic beliefs and practices (whether the person is currently active in their faith tradition or not, whether he or she speaks well of their faith or not).
3. Anxiety
Be alert for feelings of anxiety or excessive guilt over real or imagined sins, which Muslims may be at risk for (see Case #1 above). Don’t try to immediately rationalise or explain away the anxiety/guilt; rather, seek to understand it better from the client’s perspective. Identify core beliefs that may be driving the anxiety but do so without overtly challenging religious beliefs.
4. Be Supportive and Neutral
Be respectful and supportive of the Muslim client’s religious beliefs/practices that he or she finds helpful (or might find helpful in the future as a way of coping with emotional issues). However, always do so from the client’s perspective. If the client is receptive and open to healthy religious practices, and these are not clearly pathological, then these may be encouraged; if the client shows any resistance, don’t push. However, it may be informative to gently explore where the resistance to religious beliefs/practices is coming from in a future session. Never give clients the impression that they are not religious enough, since they probably get plenty of that from family and members of their religious community. Whether you are a psychiatrist prescribing biological therapies or a therapist providing counselling, the mental health professional should be viewed by the client as neutral, interested in, open to and supportive of the client’s Islamic faith tradition, but always on the client’s side and never judgemental. This advice also applies to Imams who are counselling members of their mosque. There may be some cases, as in Case #2 above, where engagement in religious activities with clients is permissible. However, even in those instances, the therapist should always provide an environment in which the client’s preferences guide their actions. Always allow the client to lead in this regards.
5. Utilise Religious Resources
If the client is religious, but not a candidate for religiously-integrated therapy or doe not prefer this approach, then the therapist should provide secular psychotherapy that is supportive and respectful of the client’s Islamic beliefs. There may be times during secular psychotherapy when the client’s religious beliefs may be utilised to support changes in attitude and behaviour. In-depth knowledge about those religious beliefs is usually necessary (guided by a detailed spiritual history, and preferably by consultation with knowledgeable experts).
6. Consider Religiously-Integrated Therapy
When clients prefer this approach and therapists are willing, religiously-integrated cognitive behavioural therapy (CBT) from a Muslim perspective for those with depression should be considered. There are resources that may help the therapist or Imam in this regard (a Muslim CBT manual, therapist and patient workbooks, and an introductory video, all without charge) (Centre for Spirituality, Theology and Health, 2014). Religiously-integrated CBT, including that from a Muslim perspective, is an evidence-based treatment that has documented effectiveness in the treatment for depression, especially in highly religious patients (Koenig et al., 2015).
7. Challenge/Re-Educate
If the client’s Islamic beliefs or practices are contributing to their psychopathology, and this is confirmed following consultation with an expert from the client’s local religious congregation (usually their Imam), then the following approach is suggested. First and foremost, the mental health professional should further inquire about the role that religious beliefs are playing in supporting psychopathology. The therapist should listen respectfully, gathering as much information as possible about the natural history of how religion became intertwined with the emotional problem. This must be done in an open and receptive manner and without confrontation (at least during this initial information gathering stage). There will come a time, once the therapeutic relationship is firmly established and the client feels safe and accepted, when gradual, gentle, and persistent “Socratic questioning” may help to guide the client towards a “healthier” use of their Islamic beliefs/practices. We emphasise gradual, gentle, and persistent questioning within an atmosphere that is safe and comfortable. Arguments over religious beliefs will almost always be unsuccessful and will adversely affect the therapeutic alliance.
8. Consult and Refer
When addressing religion or integrating it into the treatment seems indicated in a Muslim client, and the therapist lacks the desire or experience to do so, consideration should be given to consulting with, referring to, or conducting co-therapy with an imam, Muslim chaplain, or Muslim pastoral counsellor (AMC, 2016). If clergy trained to provide counselling from a Muslim perspective are not available, then the therapist should consider obtaining additional training and experience in this regard (see Centre for Spirituality, Theology and Health, 2014).
9. Non-Religious Muslims
If the client is not actively religious, then the mental health professional should proceed with secular psychotherapy that is respectful of their personal and cultural beliefs. Aggressive attempts to reconnect the person to his/her Islamic faith tradition should be avoided. If the client was once religious and has not become socially isolated or is despairing for lack of meaning in life, the therapist might gently ask if the client has considered re-establishing connections with their local faith community (or locate a different one). The therapist may help the client weigh the pluses and minuses of such re-involvement, but again always following the client’s lead.
10. Other Recommendations
Finally, for therapists who see Muslim clients on a regular basis, there are several ways to make them feel welcome. Consider providing a prayer rug in the waiting room (or have a special room for this activity), a sign on the wall that indicates the direction to Mecca, and a copy of the Qur’an readily available.
Conclusions
Based on the research, our clinical experience treating Muslim clients, and common sense logic, we make a number of recommendations for mental health professionals and clergy that will assist them in providing whole person care to Muslims. We emphasise here the importance of taking a detailed spiritual history to learn about the beliefs, practices, and values of each individual person, providing a safe place, where they can talk about their Muslim beliefs without judgement, showing respect and honour at all times for those beliefs, and sometimes, re-educating and challenging clients when they misunderstand Islamic teachings (but only if therapist is fully informed and does so in the gentlest and most supportive fashion).