Management of Psychiatric disorders- an Islamic perspective
Dr Nisar Ahmad Wani
The monotheistic religion Islam is based on revelations since Adam to the Prophet Muhammad 1400 years ago, which were recorded in the sacred Quran . The word Islam in Arabic means “submission,” reflecting the central core of Islam, which is the submission to the will of Allah.
Muslims are bound with a code of behavior, ethics, and social values, which helps them in tolerating and developing adaptive coping strategies to deal with stressful life events. Islam teaches how to live in harmony with others “Seek the life to come by means of what Allah as granted you, but do not neglect your rightful share in this world. Do good to others Allah has done good to you. Do not seek to spread corruption in the land, for Allah does not love those who do this” (Quran, 28:77).
Sharia in Islam means ‘the path’ and it refers to the path that Muslims should follow in their life. It provides the guidelines and requirements for two types of interactions: Those between humans and Allah (worship); and those between humans to humans (social transactions). The main sources of Sharia are the Holy Quran and Sunna.
The Quran describes the way in which Allah should be worshipped. The Sunna includes all the known sayings, advices, and actions of Prophet Mohammed, his decisions, and his responses to life situations and to philosophical and legal questions, which usually derived from what’s called Hadith.
According to attachment theory by John Bowlby, we know that having a secure attachment has been linked to the over-all wellbeing, coping, better mental health outcomes, enhanced self-esteem, and stronger relationship functioning. Thus, having a “healthy attachment” to Allah would also be linked to better psychological functioning: “… And whosoever puts his trust in Allah, then He will suffice him…” [Quran, 65:3].
Islam from a bio-psychosocial model perspective
In Islam, religion and spirituality are not mutually exclusive as you cannot have one without the other. Other religious and spiritual traditions may see them as separate where you can have one over the other.
From the biological perspective, different studies have found that being religious increases patients’ satisfaction and adherence to treatment.
This can be applied to Islam in the way it helps with drug adherence through encouraging Muslims to look after their health by seeking advice and receiving treatment as health is considered a gift from Allah, which should be cherished. The Prophet Muhammad has reported “down a cure even as He has sent down the disease.”
On the contrary to what is commonly thought among Western societies that Muslims believe that mental illnesses are due to demons or bad spirit-related, it was in fact the Europeans in the Medieval Period who viewed mental illness as demon-related, Muslim scholars of that time, including IbnSina (known in the West as Avicenna – the founder of Modern Medicine), rejected such concept and viewed mental disorders as conditions that were physiologically based.
This led to the establishment of the first psychiatric ward in Baghdad, Iraq in 705CE by al Razi (one of the greatest Islamic physician). This was the first psychiatric hospital in the world. According to al Razi’s views, mental disorders were considered medical conditions, and were treated by using psychotherapy and drug treatments.
Another fact which clinicians need to be more aware of is that adherence to psychiatric medications may be affected during Muslim fasting periods as in Ramadan (in which Muslims fast from just before sunrise to sunset each day), so clinicians should adjust the dosing interval according to timing of iftar and suhoor (i.e., the Muslim fasting and eating times). This can also be achieved by using alternative dosage forms for medication during Ramadan. However, if the patient’s mental condition necessitates frequent dosing, or his physical wellbeing will be adversely affected by the combined effect of fasting and psychotropics intake, which may lead to dehydration, the clinician can then advise the patients not to fast as Islam exempts them from fasting in such conditions. “And whosoever of you is sick or on a journey, let him fast the same number of other days. Allah desired for you ease; He desired not hardship for you”. (Quran 2:185).
Another detrimental factor in pharmacotherapy adherence is the presence of inert ingredients in psychotropic medications, which might be derived from pork products that may pass unnoticed by the clinicians. As ingestion of pork or any of its products is totally forbidden in Islam and it may be considered as committing a sinful act. So if this issue is not identified and addressed, then patients may not only stop taking their medications, and hence leading to relapse of symptoms, increasing hospitalization rates, and increasing healthcare costs but also lead to a poor doctor-patient relationship. The inert substances derived from pork products and frequently used in medications include gelatine and stearic acid. We believe that, in order to maintain a good doctor–patient relationship and improve medication adherence, psychiatrists should have a basic familiarity with religious dietary restrictions and they should discuss such issue frankly with their patients as a part of informed consent. This does not have its implications for patients alone but may also have ethical and potentially legal consequences for physicians as well. Regarding the psychosocial model, there is Islamic counseling, which is similar to Western counseling in the way the clients seek assistance from a suitably qualified person to deal with their psychological problems, the same may be effectively obtained from a religious leader or Imam.
The main role of the Imam in for this purpose is to provide advice which would be in accordance with the Quranic principles and teachings of the Prophet Muhammad. Muslims approach Imams for counseling on social and mental health issues and particularly marital and family problems. This form of counseling proved to be effective in improving marital adjustment levels of incompatible couples.
Another model of Islamic counseling is the traditional healing, here a traditional healer who may be a shaykh, derwish, or pir depending on their geographical location, practice various rituals to heal a client. This model explains the illness or personal problems as a possession by spirit (jinn). The solution for a healer is to exorcise the spirit, through reading Quran, prayers, playing music, dancing, and beating spirits, out of the “client’s” body, which then frees the person from misery.
Despite the support of some studies to the value of traditional healing, many Muslims do not believe in this form of healing nor consider it Islamic, which in these instances would make its use inappropriate and even banned in certain Muslim countries. Further, evidence suggests that Islamic traditional healing works mainly for treating neurotic symptoms, as opposed to severe mental or physical illness where it will fail.
Sufism is a third model of Islamic counseling, in which a trained Sufi master (shaykh) guides the person to the path to God, Initially the person needs to show his/her desire to serve God and humanity and show a commitment to act according to the master’s guidance. In his/her interaction with the master, this person expresses her/his concerns to the Sufi master who then deals with these concerns by directing the individual to the goal of detachment from the world and to the presence of God. This is usually done through the Islamic daily prayers and worship with continuous invocation of prayers and the names of God to elevate the spirit (zikr).
Sufism can have beneficial therapeutic outcomes. Even those scholars who do not agree with the traditional counseling for Muslim clients frequently consider Sufism as the basis of an original counseling model in Islam.
Nowadays, there are growing interests in Islamic psychotherapy from Western countries perspectives, which means incorporation of Islamic views of human nature while using different psychotherapeutic strategies and evidence-based treatments to help treating Muslim patients. This therapy includes using of Quranic metaphors, the Sirah of the Prophet and his traditions, as well as the biographies of the Prophet’s companions, with Muslim patients, which will provide detailed instructions for implementing successful therapy.
It has been widely known that psychotherapy is a unique art developed by the Western society during the 20th century; however, as we can find that psychotherapy was widely used in treating mental disorders all over the world for many ages before it has been started by the West.
During the golden era of Islamic civilization, the Islamic scholars had discussed the concept of psychology, psychiatry, psychotherapy, and their relationship to mental health. For example, Abu Bakar Muhammad Zakaria Al-Razi (925 CE) is the first Muslim physician who introduced the methods of psychotherapy and he had achieved a lot of success in discovering the definition, symptoms and mental health. The discussion on mental health was published in his book entitled ‘El Mansuri’ dan ‘Al Tibb al-Ruhani’.
We think that Western practitioners can enhance their ability to skillfully practice Islamically modified interventions through knowing the basic concepts of Islam and cultural norms among Muslims.
Consultation with an Imam (a Muslim religious leader), a Muslim social work professional, or another respected community member can also be helpful. They can help identify concepts, which are consistent with Islam, as well as language from Islamic teachings such as halal and haram concepts in Islam, which mean what is allowed and what is prohibited, respectively.
Nowadays, modifications have been added to different psychotherapeutic techniques in order to comply with Islamic values, for instance, Motivation-enhanced psychotherapy may be facilitated through the use of Islamic concepts, as patients’ desire to address a given problem may be aided through the knowledge that this intervention enhances their relationship with Allah..
Psychoanalytic approaches are not widely accepted among Muslims, in contrast to the concept of individualism used by Western counseling. Islam highlights the importance of community rather than looking inward to establish their identity. Muslims tend to look outward, identify their identity in religious teachings, culture, and family.
Group therapy also may be problematic for many Muslims. Although this might seem opposite to the emphasis of Islam on the value of the community, group therapy as practiced in Western settings often conflicts with a number of Islamic values. For instance, some Muslims may feel uncomfortable sharing personal details in group settings, particularly if members of the opposite gender are present. However, the functions of such groups may be enhanced if they are composed of members of the same gender and involve values taken from the Islamic faith.
Practitioners may consider using spiritually modified cognitive therapy, by replacing certain concepts used in Western cognitive therapy with concepts drawn from Islamic teaching.
Studies on Muslims that used spiritually modified cognitive therapy for anxiety and depression showed faster results as compared with the therapy that is not Islamically modified. Similarly, a study conducted on Muslims with bereavement showed significantly better results with cognitive-behavioral therapy that had been modified to incorporate Islamic beliefs and practices.
Another striking study was conducted on Muslim patients with schizophrenia in Saudi Arabia, which revealed spiritually modified cognitive therapy was either similar, or superior, to the results achieved with traditional cognitive therapy.
Although these researches revealed how effective the cognitive interventions based on Islamic principles for Muslim clients was, there are concerns regarding various methodological issues used in these studies, particularly small sample sizes. This reflects the utmost need for more research in this area to make definitive statements about the empirical soundness of such approaches.
In spiritually modified cognitive therapy, we follow the cognitive restructuring model, where the therapist identifies the patient automatic thoughts and core beliefs. The process would then involve an evaluation and modification of automatic thoughts, followed by modification of core beliefs and assumptions. Modification occurs mainly through examining the evidence and looking for alternative explanation.
Therapist can use cognitions from the Islamic faith and offer it as an alternative explanations to dysfunctional thoughts associated with a variety of conditions or disorders.
There are several significant cognitive themes from the Islamic faith that can help to adapt the patients’ cognitive errors.
We have reviewed different studies and books and tried to explore the impact of Islamic values and beliefs on modification of the patient cognitive errors, and how these Islamic values can even help in prevention of different psychiatric disorders.
It is a normal reaction toward any life losses. Muslims believe that all suffering, life, death, joy, and happiness are derived from Allah and that Allah is the one who gives us strength to survive. They believe that any loss or deprivation experience is a form of a test from Allah to his slave of how he will stand this suffering with patience and full trust in Allah’s mercy.
These beliefs usually help to comfort and aid the healing process. For example, in accepting grief and loss, the relatives of the deceased person are urged to be patient (sabr) and accept Allah’s test. ‘Be sure we shall test you with something of fear and hunger, some loss in goods, lives and the fruits of your toil, but give glad tiding to those who patiently persevere. Who say, when afflicted with calamity: To Allah we belong, and to him is our return’ (Quran: 62).
People who have patience in accepting Allah’s decree will be given a reward from Him. The Prophet Muhammad said: “No person suffers any anxiety or grief, and says this supplication but Allah will take away his sorrow and grief, and give him in their stead joy
However, Muslims are not immune against the feeling of grief. It is permissible to cry and express grief over the death of a loved one. For instance, when the Prophet’s son, Ibrahim, died, the prophet said ‘We are very sad for your death, O Ibrahim’,Islam encourages Muslims to talk about and remember their loved one and recall the good deeds of their life. Prophet Muhammad himself never forgot his love for his beloved wife, Khadijah, even years after her death.
During grief reaction a person may have negative thoughts such as “Why is this happening to me?” “Why not someone else?” “Why did Allah choose me for this unbearable trial?” or “Allah is punishing me for my disobedience”. This is accompanied with anxiety and fear of Allah’s punishment, both in this present world and the hereafter. Most of these patients come from families raised with a strong faith in Allah, but with an exaggerated sense of His punishment; God’s love and mercy are diminished in their relationship with Him. In therapy these patients may improve with interventions, such as modification of cognitive errors that focus on these thoughts and beliefs.
Prophet Muhammad said, “No Muslim is struck with an affliction and then says Istirja’ (‘Truly, to Allah we belong and truly, to Him we shall return’) when the affliction strikes, and then says, ‘O Allah! Reward me for my loss and give me what is better than it,’ but Allah will do just that”
It is a disorder in which unwanted thoughts and acts take hold of the individual.
From an Islamic perspective, these unwanted obsessive thoughts are called wasawis (plural of waswasah), which are whispered into the minds and hearts of people by Ash-Shaytan (Satan). We can find evidence of this in the holy Quran and Hadith .
Allah says, “Then Shaytan whispered suggestions to them both,in order to uncover that which was hidden from them of their private parts” (Quran7:20).
[Say: ‘I seek refuge with Allah, the Lord of mankind, the King of mankind, the God of mankind, from the evil of the whispers of the Devil, who whispers in the hearts of men’] (Quran 114:1-4).
And the Prophet Muhammad said “Shaytan comes to one of you and says, ‘Who created so-and-so and so-and-so?’ till he says, ‘Who has created your Lord?’ So, when he inspires such a question, one should seek refuge with Allah and give up such thoughts” (Al-Bukhari and Muslim).
All human beings experience at some point in their life wasawis, regardless of age, sex, faith, or creed. However, the nature, content, severity, and influence of these wasawis vary from one person to the other. For some, they only cause mild anxiety and worry, while for others may be more severely affected to the point of becoming spiritually, mentally, emotionally, psychologically, and socially incapacitated.
We find in the holy Quran the counter adaptive thoughts for these obsessions (wasawis as called in Islam)
[So when you intend to recite the Quran, seek refuge with Allah from Shaytan, the outcast. Verily! He has no power over those who believe and put their trust only in their Lord (Allah). His power is over those who obey and follow him (Shaytan) and those who join partners with Allah] (Quran 16:99-100).
[And deceive among them those whom you can with your voice. Verily! On my true servants, you would have no authority. Sufficient is your Lord as a guardian] (Quran 17:64-65).
Moreover it can help to relieve the guilt feeling which is associated with the obsessions of religious nature.
As the Prophet (peace and blessings be upon him) said “Allah Most High has forgiven the wasawis that arises in the hearts of the people of my nation until one acts upon them or talks about them” (Al-Bukhari, Muslim).
It is a feeling of worry, nervousness or unease about something with an uncertain outcome and strong desire or concern to do something for something to happen.
As cognitive errors are common to be similar in anxiety and depression, the above examples can be used in anxiety as well.
In addition, anxious patients may have maladaptive thoughts such as “I feel that I am no longer able to cope,” “Life is too difficult for me,” or “No one is there for me.” It can be helpful for those who are suffering to recall that Allah is always there and can assist those who place their trust in Him.
One of the foundations of Islamic belief is the understanding that Allah is able to do all things and He runs all affairs. This is an aspect of tawheed (belief in the oneness of Allah) that specifies oneness in Allah’s Lordship.
“And when you have decided, then rely upon Allah. Indeed, Allah loves those who rely [upon Him]” (Quran, 3:159).
It is reported in a Hadith on the authority of Abdullah bin Abbas, who said: One day I was behind the prophet and he said to me: “Young man, I shall teach you some words [of advice]: Be mindful of Allah, and Allah will protect you. Be mindful of Allah, and you will find Him in front of you. If you ask, ask of Allah; if you seek help, seek help of Allah. Know that if the Nation were to gather together to benefit you with anything, it would benefit you only with something that Allah had already prescribed for you, and that if they gather together to harm you with anything, they would harm you only with something Allah had already prescribed for you. The pens have been lifted and the pages have dried” (Zarabozo, 1999, Hadith 19, pp. 729-730).
Other cognitive adapting techniques that can be used to relieve stress and help in anxiety as well as depression, is to count how much God has blessed us and trying to focus on what we have and not on what we are deficient in.
Prophet Muhammad said, “Look at those who are less fortunate than yourselves, not at those who are better off than yourselves, so that you will not be little the blessings that Allah has bestowed upon you” (Al-Mundhiri, 2000, n.d., book 68, chapter 13, p. 1115).
Other way of cognitive restructuring is to help Muslims to learn from the Prophet Muhammad teachings that do not regret for things that have happened in the past, which one cannot go back and change, and to worry about what may happen in the future is useless. The person should think only about the present, focusing his energy on doing his best today, because this is what results in perfect work, and helps him to forget his worries and regrets and as the prophet said: ‘The strong believer is better and more beloved to Allah than the weak believer, and both are good. Pay attention to that which could benefit you, seek the help of Allah and do not feel incapacitated. If anything befalls you, do not say, “If only I had done such-and-such, such a thing would have happened.” Say instead, “It is the decree of Allah, and what He wills, He does,” for saying “if only…” opens the way for Shaytan.’”
The feeling of of severe dependency , dejection . A mood or emotional state that is marked by feelings of low self -worth or guilt and a reduced ability to enjoy life.
Negative life events are one of major risk factors for depression.
Islam plays an important role in helping Muslims to cope with negative life events, which helps them in both prevention and treatment of depression. Muslims are not superhuman, however, if one experiences negative feelings, he is encouraged to resist them with positive thoughts and actions if possible, or to seek professional help if the case is clinical, exactly like any other form of illness.
“So, verily, with every difficulty, there is relief: Verily, with every difficulty there is relief.” (Quran, 94: 5-6)
Islam encourages people to stay hopeful, even if someone has committed the worst sin or faced with most troublesome life event as there is always God’s mercy.
“And never give up hope of Allah’s soothing Mercy: truly no one despairs of Allah’s soothing Mercy, except those who have no faith.” (Quran, 12:87)
To counter maladaptive thoughts related to hopelessness and feeling overwhelmed with life, as there is no place for despair because Muslims believe that it is God Himself who is in charge of everything, the all Seeing, All Knowing, and All Fair and Wise God.
As God says: “And for those who fear Allah, He always prepares a way out, and He provides for him from sources he never could imagine. And if anyone puts his trust in Allah, sufficient is Allah for him. For Allah will surely accomplish His purpose: verily, for all things has Allah appointed a due proportion.”(Quran, 65: 2-3)
Alcohol and substance abuse
Alcoholism is not a huge mental health problem among Muslims in comparison with Western society as Islam prohibits alcohol and substance use among Muslims. th
There are two main features of Islamic prohibitions:
- a) Islam stops the wrong doing from its roots and not at the end. There is no specific age for drinking, or safe drugs to get high. As in Western countries most of the teenage alcoholics do not buy the alcohol from the store but get it at home. Islam prohibits drinking completely (total abstinence) for all Muslim of any age and sex. It is the reason why the West finds it a difficult issue to manage the problems of drugs and alcohol, because it has made double standards.
- b) Islam prevents Muslims from following the path, which may lead to drug and alcohol intake. Therefore not only promiscuous sex is prohibited, but casual mixing of sexes freely is also prohibited, obscenity and pornography is also prohibited. The drinking of alcohol, or to come in contact with alcohol or any other spirits such as making, selling, keeping them, or even growing grapes for the sole purpose of selling it to winery for making wine is prohibited. As mentioned in Quran.
“They ask you concerning wine and gambling.” Say: “In them there is great sin, and some profit, for men, but sin is greater than the profit” (Quran 4:43)
“O you who believe! Approach not prayers, with a mind befogged, until you can understand all that you say”(Quran 2:219).
“O you who believe! Intoxicants and gambling, (dedication of) stones, and (divinations by) arrows, are an abomination of Satan’s handiwork: Avoid such (abomination) that you may prosper” (Quran 5:93).
“Satan’s plan is to sow enmity and hatred among you with intoxicants and gambling, and to hinder you from the remembrance of Allah and from prayer. Will you not then give up” (Quran 5:93).
Prophet Mohammed said:
“Of that which intoxicates in a large amount, a small amount is haram” (Ahmad, Abu-Daud and Al-Tirrnizi).
“Khamar (intoxicants) is the mother of all evils” Reported in Bukhari.
Meditation is based on concentrating on any one idea or object to the exclusion of all other ideas or objects.
Meditation works by eliciting the relaxation response. The relaxation response is characterized by decreased heart rate, respiratory rate, oxygen consumption, and muscle tension. Studies revealed that meditation helps in the reduction of total and low-density lipoprotein (LDL) cholesterol, decreased anginal symptoms, and regression of coronary artery disease.
Meditation by focusing on Allah’s creatures (plants, animals, space, human body, etc.) is considered one of the most efficient and powerful forms of Islamic worship. In fact, the Quran describes Muslims involved in such a process of meditation as:
Men who celebrate the praises of Allah standing sitting and lying down on their sides and contemplate the (wonders of) creation in the heavens and the earth (with the thought): “Our Lord! not for naught hast thou created (all) this! Glory to thee! give us salvation from the penalty of the fire: (Quran, 3: 191)
Other forms of meditation may be enhanced by the recitation of one word or a few words that give the person a sense of internal peace and calm, which is known as remembrance (zikr) in Islam; for example, by repeating the words subhan Allah (glory be to Allah) or al-hamdulillah (all praise be to Allah). It also adds an additional factor that helps in stress elimination and that is giving the individual the feeling that he or she is in extreme proximity with Allah, the Controller of the whole world.
Muslims prayers themselves can be considered as a form of meditation and remembrance as while praying, Muslim feels that he is in extreme connection with the controlling power of this world (Allah) and that from Him he receives maximum support.
O ye who believe! seek help with patient perseverance and prayer: for Allah is with those who patiently persevere. (Quran, 2: 153).
Prophet has said: “your prayers are like a flowing river at your doorstep you wash yourself in it five times a day.”
Recent studies showed that praying reduces postoperative complications following open-heart surgery. Praying also lowers the incidence of depressions in patients following hospitalization. Recently, it is recommended that praying can be used as an alternative therapy as successfully as meditation, exercise, or herbal treatments.
In summary, there is a huge impact of Islamic religion and spirituality within psychiatric clinical practice. Using Islamic values and beliefs are the best ways in treatment of mentally ill, through incorporation of Islamic beliefs that help in drug adherence and modification of different psychotherapeutic techniques to suit the patients. Such aspects provide the basis for specific guidelines in working with mental health clients.
(The author is a Senior Assistant Professor at Govt. Degree College For Women, Anantnag)