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Issue of Religiosity in Mental Health: Are We Forgetting The Missing Link? Abul Hussain In
recent decades concern has developed about inequalities in mental health
and health care delivery between the ethnic majority and Black ethnic
groups. Research (Fernando,
1995; Browne, 1997) findings have shown overrepresentation of Black
groups, many of whom from Muslims backgrounds, in the psychiatric
system. Furthermore
research has found that Black ethnic groups are more likely than the
ethnic majority to be: admitted to hospitals under compulsory sections
of the Mental Health Act (1983), deemed to require urgent treatment and
placed on locked wards. Black groups are also more likely to be diagnosed as
suffering from schizophrenia, given high doses of neuroleptic drugs and
less likely to be offered non-drug based treatment such as talking
therapy. In short they get
the rough, hard end of mental health care.
Black writers (Kareem & Littlewood, 1992; Fernando, 1995;
Robinson, 1995) have highlighted the mistreatment of black patients
arguing that this stems from racial stereotyping and cultural
imperialism adopted by mental health professionals, who view Black
ethnic groups as being: unable to express their emotions, hostile in
attitude, not motivated for treatment and not psychologically minded.
Certainly the diagnosis of psychiatric disorders, if not carried
out by white middle class psychiatrists, is based on the ethnocentric
knowledge base of Western medicine.
No real attempt is made to develop any detailed understanding of
how Muslim patients' religious beliefs influence their thinking about
health, illness and treatment. Yet there are an estimated 1.8 million Muslims living in the
UK (Muslim News, 1998). The
few Muslim mental health professionals within mainstream mental health
services, such as myself, exist in the two cultures that are worlds
apart finding it difficult to narrow the gap between them.
This
paper is thus my attempt to build bridges by informing other mental health
workers how they might better understand the contrasting the value system
of the Muslim Ummah (community) against that of secular psychiatry.
Islamic beliefs have a central role in the lives of many Muslims,
such as myself. Sarwar
(1998), describes the belief system or articles of faith in two
dimensions, the internal and external forms of worship (ibadah). The
internal form of worship is referred to as ‘imaan’ and has seven
facets, which includes belief in: Five
basic duties or pillars constitute the external form of the worship.
These include: It
is generally held that our faith protects us from ill health as well as
helping us manage health problems when they do occur.
The fact that Islam plays a major part in shaping the Muslim's
understanding, experience and expression in mental distress is
well-documented (Ansari, 1992; Hussain, 1999; Badri, 2000).
Amongst Muslims there is a strong tendency to conceptualise illness
as occurring according to the will of God (Allah), who is understood to be a higher power that cannot be
perceived by the senses. Central
to this belief is the idea of Al-Qadar.
It is believed that everyone's Qadar is written from the moment of
conception. Whatever happens
in life is written in Qadar and can never be changed, except through
supplication, which is in the grace of Allah whether to accept or not
(An-Nisa 4:48). Allah is the
architect of destiny and the advancement of the individual is dependent on
Him. All life events are
under His control and can be changed by Him alone.
This belief is fortified in the Holy Quran in Surah At-Taghabun
(64: 11): "No calamity befalls, but with the
leave of Allah (i.e. what has befallen him was already written for him by
Allah from the Qadar, Divine preordainment)… and Allah is the All-Knower
of everything". In
many cases, human suffering is also looked upon as being a means to an
end. For, Prophet Mohammed
says that when one is afflicted with pain they should not complain and
instead endure illness patiently, as illness is a way of being forgiven
for sins and balancing the rewards. Illness
is also understood as a trial on people placed by Allah to test their
level of piety, devotion and reliance.
Nasiruddin al-Khattab expounds this further when he says:
"Patience means to keep close to Allah and to accept calmly the
trials He sends, without complaining or feeling sad" (1997: 7).
Some have also noted that people with ill-health are asked to pray
for others, as they are regarded to be purer in Allah's sight;
supplications from them are thought to be more likely accepted by Allah.
Alongside this belief, black magic (witchcraft or sorcery), spirit
possession (jinns) or evil eye (ayn, nazar), are also believed to be
negative forces or spells that are responsible for emotional distress or
irrational behaviour. While
nazar can be caused unintentionally by an envious glance (Sa'eed Ibn
Ali-Ibn Wahf Al-Qahataani, 1996) and be responsible for many common
emotional stresses - these acts are thought to be attributes of those who
transgress the Islamic sanction. When
afflicted by such phenomenon Muslims frequently turn to the Quraan (Al-Bakarah
2: 255, 285-286; Ya-Sin 36; Al-Falaq 113; An-Nas 114 etc) for salvation.
It
is also commonly found that emotional stresses are essentially
communicated through somatic or physical complaints. The upper body and mainly the heart (ruh, nafs, qulb) is
commonly indicated to be the location of emotional pain. Somatic symptoms have far more importance in the Muslim
cultural system. Here the
perception is one of the connections between "psyche" and
"soma", the multiple ways in which physical and psychological
problems interact. Therefore, the distressed person primarily notices and
reports somatic symptoms. Mental
unrest is thought to be the manifestations of an incongruent heart - an
unstable soul - that is lost and so has become distant from its 'creator',
Allah. In this sense, a
stable or sound state of mental health is a "well" or
"true" or "clean" or "guided" heart that is
calm and so is within the sanctions of Islamic teachings.
A "rusted" or "hard" heart is a symptom of
chronic ill feelings and ultimately God's displeasure. This state is
described mainly as an aching heart, a trembling heart and pressure in the
heart. While the head is the
vital and animating principle, the heart / soul is the locus of thought,
feeling, awareness and memory. One
"thinks", "becomes aware" or "recalls" in
the heart (Al-Munafiqun 63:3; Al-A'raf 7:179).
Thus, "illness" is the illness of the heart or body.
This mode of articulation is not to say that thinking in the heart
is emotional illiteracy (an inability to understand and communicate
emotions adequately), but that it is thinking that is metaphoric and
closely connected to feelings. This
feature of expression is rooted in the Quraan in Surah Al-Baqarah (2:10):
"In
their hearts is a disease (of doubt and hypocrisy) and Allah has increased
their disease. A painful torment is theirs because they used to tell
lies". The
significance of the heart as a living entity is also indicated in Bukhari:
"Beware!
There is a piece of flesh in the body.
If it is healthy, the whole body is healthy. If it becomes unhealthy, the whole body gets unhealthy - that
is the heart" -
(Ansari, 1992: 7) As
mental distress in the practising Muslim community is generally expressed
as moral transgression or the result of Divine Will, religious
interventions or methods are frequently resorted to for healing.
Fasting (sawm) , repentance (taubah) and regular recitation (zikr)
of the Quraan are common features of the treatment and healing process.
Thus the belief in the treatment is closely tied with the belief
about illness. Underlying
this belief is the idea of regaining connection and intimacy with Allah
and in the process enabling one to gain a cognitive grasp of their
situation. This is expected
to reduce motivation for sin and relief from distress, which leads to
better health. This
understanding is reinforced in the following verses of the Quraan:
"He who does evil or wrongs himself, but then seeks
forgiveness of God, will find God Forgiving, Compassionate" (Al-Nisa
4:10)
"….If
Allah is your helper none can overcome you and if He does not help you,
who is there to help you? The reliant rely only on Allah" (Al-Imran
3:160) "Surely
in the remembrance of Allah do hearts find rest" (Ar-Ra'd 13:28) Outside
the spiritual sphere biomedical psychiatry, part of western medical
tradition, attaches its explanation of human distress to an individual's
biological body. In this view
distress is understood as a defect in the hormonal mechanisms that control
the balance of emotions and thoughts i.e. levels of serotonin and dopamine
which causes chemical imbalance of the brain.
It deals with the classification, diagnosis and treatment of those
people it determines as mentally ill on the basis of a wide range of
clinically symptoms. This
means that the person is seen in isolation from their religious, social
and environmental factors. This
idea is based on the philosophical concepts of Cartesian dualism (the
secular idea that mind and body are separate entities), which are present
in western cultures. Thus the total experience of the person is divided into
various components, such as 'hearing voices', 'feeling depressed' etc.
What this means is that, other life events, such as belief in
Higher Power as in Allah and the consequences of inequality, which play an
important part in shaping peoples' experiences and concepts, are
systematically played down. Ultimately
then, this implies that the part religion plays in understanding the
meaning of human suffering are of little value in helping us understand
the origins of human distress. The
biomedical model assumes that distress has no intrinsic value and so must
be dealt only with anti-depressants or modern technical interventions such
as cognitive-behavioural psychology.
The
problem with this western secular, scientific approach is that it denies
any significance to any other understandings of mental health and illness,
such as those of Muslims. While an understanding of distress in the
western culture focuses on the "individual", Islam teaches us to
look beyond ourselves and focus on being God-conscious (the relationship
with Allah). How much sense
is it to prescribe tablets to someone who perceives their problem to lie
in some religious maladjustment? Can
psychiatrist achieve credibility within the Muslim community if they
regarded mental health practitioners as godless and ill equipped to deal
with complex psycho-religious issues?
Can a psychiatric assessment achieve its full value in such a
context? How far are Muslim
groups able to realise their inner strengths and resources without a wider
mechanism that supports the context in which they internally grow and
live? Does the increase in the secularisation of western societies
contribute to a view that sees religious or spiritual belief as
symptomatic of mental illness? The
questions raised tell us how western mental health care is failing to
recognise differing ideas about life, approaches to life's problems and
beliefs and feelings that come from non-western cultures such as Islam.
Western mental health workers could therefore do a lot towards
bridging the gap and empowering their Muslim clients’ by simply saying
to them: ‘I don’t know much about your culture of origin but I would
be interested to hear about it from you’.
This may help to narrow professional and client power differences
and increase effective communication across cultures.
Given the belief that clients from Muslim backgrounds view
‘self’ in the collective community and spiritual sense (Badri, 2000),
it will also be useful for mental health workers to help clients explore
and access resources available in their own community, such as Mosques
rather than be restricted to mainstream services alone.
This may help to increase clients’ integration with their social
being and whole self and therefore lessen feelings of alienation.
Speight et al (1991) argue that this type of non-directive approach
acknowledges that cultures are at play and can be used to help an
understanding of where the client is coming from, putting their life
experience in context. Being a social worker with a Muslim
identity working in the mental health system, in which the medical model
dominates, can raise some professional conflicts.
Reflecting on my own experience, I have learnt that when these
difficulties remain unresolved, maintaining professionalism can become a
frustrating process, hindering my personal development and effective
multi-disciplinary team work. What
has helped me to deal with these dilemmas is support from other members of
the team, who are committed to anti-discriminatory practice.
Through this we have created a forum where ethical practice issues
can be safely discussed and pursued. This helps to raise awareness of
organisational prejudice and bring a more reflective perspective to
working with multi-ethnic groups. If
we are to value the diverse expression of human life, we have to be open
to religious systems embodied within a culture that determines how life is
conceptualised. If mental
health workers are to develop a deeper understanding of ways of life and
death, they need incorporate into their western scientific professional
knowledge base some respect for the spiritual sanctions or maps that are
being generated within the cultures of the people they attempt to care
for. From this standpoint, it
can be gathered that learning about the concept of 'after-life' (known as
akheerah in Islamic terms) and how it relates to some of the symbols
within 'God-conscious' communities are useful starting points in
increasing empathy and sensitivity towards these groups.
In other words, working along side religious discourses is a step
towards realising the vision of the worlds of others.
Writers from psychospiritual perspectives (Badri, 2000) say that
because of the under-value of the religious paradigm, too much emphasis is
now placed on ‘cultural differences’ to the exclusion of the belief
systems, which underpin a culture and is an integral part of it.
More importantly they point out how a Western world-view approach
to understanding community mental health needs now to engage in dialogue
and include the context of 'faith communities'.
For many people, religious faith or spirituality can act as part of
the holistic healing process. It
can be part of finding that 'centre' - the balance - that gives calmness
and peace, which is so vital to recovery.
Spiritual principles and values need to be closely explored if
mental health professionals are to really appreciate and work creatively
with the richness of a community in all its facets. References Al-Hilali
M & Khan M (1993), Interpretations
of the Meanings of the Holy Quran in the English Language, Maktaba
Dar-Us-Salaam, Riyadh, Saudi Arabia.
Ansari
Z (1992), Quranic Concepts of
Human Psyche, Islamic Research Institute Press, Pakistan. Badri M (2000), Contemplation: An Islamic Psychospiritual Study, The International Institute of Islamic Thought, Cambridge University Press, UK. Browne D (1997), Black People And Sectioning: A Study of Black Experience of Detention Under The Civil Sections of the Mental Health Act, Little Rock Publishing, London. Fernando
S (1995), Mental Health in a
Multi-Ethnic Society, Routledge, London. Hussain
A (1999), An Exploration into the
Importance of Understanding Cultural Issues in the Presentation of Mental
Distress in Bangladesh, Unpublished Paper, University of East
London. Kareem
J & Littlewood R (1992), Intercultural
Therapy: Themes, Interpretations and Practice, Blackwell Science,
London. Sarwar
G (1998), 5th Edition,
Islam: Beliefs and Teachings, Muslim Education Trust, London. Muslim
News (1998), Muslim Population in
Britain, Unpublished Paper, UK. Nasiruddin
al-Khattab (1997), Patience and
Gratitude, TA-HA Press, London. Robinson
L (1995), Psychology for Social
Workers - Black Perspectives, Routledge, London. Sa'eed
Ibn Ali-Ibn Wahf Al-Qahataani (1996), Hisnul Muslim, Safir Press, Riyadh,
Saudi Arabia. Speight,
Myers, Cox and Highlen (1991), A Redefinition of Multicultural Counselling, Journal of Counselling and
Development, 70, Sept./Oct.1991.
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