Islamic Religious Experiences and Concepts in Clinical Psychiatric Practice
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Slide 1 :
Islamic Religious Experiences and Concepts in Clinical Psychiatric Practice Walid Sarhan F.R.C.Psych Consultant Psychiatrist Amman-Jordan APA-Philadelphia 2012
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Declaration of interest none
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Introduction Islam is not merely a religion but a complete system of life. Nearly one-fourth of the world’s population today is Muslim. Over fifty countries have majority of Muslim populations, while other groups of believers are clustered in minority communities on nearly every continent. Although Islam is often associated with the Arab world , fewer than 15% of Muslims are Arabs, while 5.5% of Arabs are Christians.
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CULTURE AND RELIGION Muslims may simply inherited their religion as they are born to Muslim families, then may follow the rituals or not and may be really faithful or not whether they practice the rituals or not. However they all share the culture of Islam, and even the Christian Arabs demonstrate a clear impact of this culture. Non-Arab Muslims usually have many cultural elements that could be mixed with their religious beliefs’ and practices.
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3 Clinical Cases
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The Guidance Prayer (Istikhara prayer) It is one practice some Muslims may choose to do to seek help from God ( Allah) in making important decisions in their life. when they are uncertain about the best option, like getting married to a certain person or buying a house or changing work. Following the prayer, the person develops a sacred feeling that enables him to take the decision; this helps them to reach important decisions in their lives.
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Ahmad Ahmad 29 year's old, single banker was receiving psychotherapy for (GAD) on a background of obsessive personality disorder. I was seeing him weekly for the previous 3 months and He was making a good progress when his (Sophie) teacher suggested to him a girl to get married to. He met her few times ,but he was reluctant because of previous divorce, and also his psychiatric condition, as a solution for this , the teacher suggested that he should pray for guidance (Istikhara) , which he did, and the result was negative as he knew by the feeling he had after praying, that he could not really have a happy marriage with this girl.
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Disappointment That was enough to cause him a severe relapse of his anxiety symptoms .this made him seek my advice again. He became tearful and sad as he could not sleep his night, and could not think and was overwhelmed by the feelings that he was going to disappoint his teacher by rejecting this marriage. Furthermore he was very upset as he did not listen to my advice 3 months earlier, when he asked me about marriage and changing his job and my advice was not to take major decisions until he recovered from his anxiety.
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Therapy With the Religious Teacher Ahmad was also upset as he did not tell the teacher that I advised him not to go into major decisions, and he felt very guilty and that he should proceed with marriage and not to let the girl down. The girl realized that he was reluctant and she was ready just to withdraw or proceed whatever way is good for Ahmad, and this made things worse.
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The relation between praying and anxiety The important question was clear from Ahmad, the teacher and the girl: Could anxiety have affected the feeling after the guidance prayer? My answer was: yes, it could and even the decision to go on with marriage might have been affected by the psychological state. I suggested postponing the whole marriage issue until Ahmad recovered.
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Marriage and Depression Ahmad disappeared for 6 months to appear again in a major depressive episode (MDE) with GAD and serious suicidal thoughts. He went on with the marriage and everything went wrong even the marriage was non -consummated and eventually after 4 months, the wife asked for divorce. After the divorce he got worse, this was a month before this meeting.
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Hospitalization Ahmad reached the point where the only explanation for him was, the whole mess in his life was due to the fact that he is not a good Muslim, and that he is better off dead, knowing that suicide will make him an infidel. He was hospitalized and intensive care including sessions of psychotherapy ,that sometimes was jointly done with the teacher. Even after Ahmad was discharged, the psychotherapy continued for 3 months with excellent recovery. In the next year he met the same girl again and prayed for guidance and got married again. Follow up for the last 2 years, showed excellent recovery of both MDE and GAD.
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The lessons from the case of Ahmad Understanding the Sophie relationship with the teacher is essential to understand the problems of Ahmad. Understanding the guidance prayer and the sacred experience of decision afterwards is a central point in his condition. Cooperating with the teacher is important through the joint sessions, where the teacher can state clearly the religious point of view, reflecting the cognitive help for Ahmad, something which neither I could do on my own nor the teacher could do it alone.
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The lessons from the case of Ahmad –cont. Throughout Ahmad was testing my ability to understand his religious concepts, in spite the fact that his teacher was the one who recommended me in the first place. This is a learnt lesson of the importance of clear understanding by the therapist of the details of the religious misconceptions and issues raised by the patient.
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The evil eye (ayn al-?asud) The evil eye is a look that is believed by many cultures to be able to cause injury or bad luck for the person at whom it is directed for reasons of envy or dislike. Evil eye, (Isabat al-’ayn,) is a common belief amongst Muslim’s culture, that certain individuals have the power to look at people, animals or objects to cause them harm. But talismans and images with an eye cannot be used to ward off the evil eye. The Prophet Muhammad (peace be upon him) prohibited the use of talismans as protection against the evil eye.
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The evil eye (ayn al-?asud) cont. The form of protection allowed and practiced among many Muslims, that if a compliment is to be made, you are always supposed to say "Masha ‘Allah” ("What God wills") and also "Barak ‘Allah” ("Blessings of God") to ward off the evil eye, If it happens, reading certain versus from holy Quran on the victim, called spell legitimate (Alroqyah) to remove the influence of the evil eye
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Noora is 25 years old married Muslim housewife; she is the second wife of a Jordanian businessman, she has been married for 3 years, she has a university degree in history. I met her for the first time in the hospital; she was admitted with severe extrapyramidal symptoms (EPS). A week earlier she had an abortion for the third time and became very upset crying all the time refusing to eat or drink. A traditional healer saw her and recommended that she drinks from a bottle of water he gave her after he read certain versus from holy Quran to remove the evil eye effect of the first wife (Fatima). Noora
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Faima-the first wife Noora drank the water, but she did not improve, she was screaming and very angry with Fatima, who did not get pregnant after 10 years of marriage. Now things became clear to her and blamed Fatima for the 3 abortions. The second healer who supported the diagnosis of the evil eye and added to it the black magic, he gave her olive oil that he read on ,to be used to massage the whole body twice daily ,but as she was very weak not eating or drinking, he advised taking her to the hospital for intravenous fluids, the family accepted the advice but Noora was getting worse ,very agitated threatening to kill Fatima.
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Diagnosis Problems After midnight she tried to stab Fatima with a knife but she was stopped by the family with great difficulty. She was seen by a psychiatrist in the emergency department of a general hospital who diagnosed her to have an acute psychotic episode and gave her Haloperidol intramuscularly with some oral medications, she calmed down but refused to eat or drink for the next 2 days and developed EPS and was admitted to the psychiatric hospital.
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Depression not psychosis After rehydration and resolution of EPS, she was clearly very depressed and regretted the attempt to stab Fatima, she was always on good terms with her and was questioning the point of evil eye and black magic. The husband shared her view and both of them asked my opinion, I explained to them that she is suffering from depression and it can be treated.
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Spell legitimate Noora and her husband were interested in what I think of spell legitimate(Alroqyah) which will protect Noora from the effect of the evil eye or black magic if they are causing any problems, alongside the conventional psychiatric treatment of her depressive episode, which has started at least 6 months back following the second abortion. Spell legitimate is simply reading versus from holy Quran by somebody whom is a trusted Muslim scholar not a healer who reads on water or olive oil, as such healers are considered jugglers, and the prophet, peace be upon him, warned: Who visited a fortune-teller his prayer will not be accepted for forty days.
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Mechanism of action of Alroqyah Noora and the husband accepted my advice and continued antidepressants and cognitive psychotherapy, with Alroqyah with a very good recovery. An issue Noora would bring up in every session was: how she should deal with Fatima? She is like an older sister who could never want to harm her, why did the two healers agree that Fatima was behind the abortions? To her both are (sheikh) as well as the one! Who did the Alroqyah? The difference was explained to her, and then she challenged the idea of science accepting Alroqyah.? The faithful person is influenced by listening to Quran and that could go from the brain through the psychoneuroimmune and psychoneuroendocrine systems to help healing the body and the soul, this made sense to Noora.
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The wrong diagnosis of psychosis could happen ,when the religious understanding of the patient's symptoms is missed. The knowledge of different practices among healers should be known to the therapist. The therapist needs to know about the true religious facts as the patients do not necessarily know all the facts, the therapist may need to read the facts or consult religious scholars. Lessons from the case of Noora to be learnt
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Lessons from the case of Noora to be learnt-cont. The management as known in standard practice should go alongside the faith healing that is not going to affect the patient negatively, but have synergistic effect. Treating Noora properly without understanding the evil eye, black magic, and Alroqyah was not possible.
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Muslim’s concept of Jinn Throughout history, man has always had a deep attraction for the supernatural and the unseen. The existence of a world parallel to our own has always fascinated people. This world is commonly referred to as the spirit world, and almost every set of people have some concept of one. Islam says: The Jinn are beings created with free will, living on earth in a world parallel to mankind.
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Muslim’s concept of Jinn-cont. The Arabic word Jinn is from the verb 'Janna' which means to hide or conceal. Thus, they are physically invisible . In psychiatric practice, patients usually attribute visual, auditory and tactile hallucinations to the Jinn . Their families and the healers (jugglers) hold the same belief, but if the patient is not psychotic the mention of jinn could be very confusing in reaching the diagnosis.
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Deena Deena is 35 years old lady married teacher of mathematics, who presented with panic disorder for the last 3 years, she was not responding to treatment offered by more than one professional. She developed multiple phobias, including agoraphobia, phobia of praying, phobia of bathing with depressive symptoms and she could not work anymore.
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Uncooperative The history was given by her angry husband and she did not want to say anything, she only asked for the change of her medications. She refused to be interviewed alone, and I had to adjust her medications, and stressed the importance that she should tell me what is happening. For the next three sessions, there was little change. On the fourth session she said: I heard you last night on the TV program,( Sheikh Alkaiat) who is a well-known Muslim scholar who said that: Jinn could not harm people and they are supposed not to have any relationship with human being.
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The effect of religious scholars Deena :I was surprised and I talked directly to him on the phone about my problem, and he advised me to see you, as my problem at the beginning I had panic disorder and agoraphobia but later my fear became- different- only from Jinn. I feel they are present, I do not see them or hear them. This started 6 months after I became sick, I had visited a lady who reads Quran. The lady told me that- the panic never comes without a reason, you must have done something bad that upset the Jinn- but I was surprised, what could I have done? the lady enquired whether I had ever poured very hot water in the bathroom without saying the name of God? I said probably I did, she then confirmed that:" I am annoyed and afraid as I am touched by (mass) Jinn.
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The effect of religious scholars-cont. Since that day I stopped the medications without telling anybody and went on with psychotherapy sessions, just to please my husband and gradually I became preoccupied with Jinn and felt them in the bathroom first and later on everywhere. I stopped praying and my life became focused on the matter. Furthermore, I am visiting many healers, sheikhs, jugglers and fortune teller as much as I can, and all of them agreed that I am in a war with world of Jinn and tried to help me with no benefit
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Laughing on religious thoughts In fact I did mention the fear of Jinn to one of my doctors who laughed at me. You can always learn more about jinn from reliable sources She needed to start over again and challenging the fear that was created over two and half years, she agreed and started to take medications with cognitive behavioral therapy. Over the next 6 months Deena made a very good progress and went back to work with some residual agoraphobia.
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The concept of Jinn is widely spread among Muslim communities, with so many common misunderstandings, misinterpretations, and misbeliefs that are not in the genuine Islamic teaching. Mental health professionals need good knowledge about the matter of Jinn, and it’s unethical to laugh about the patient's beliefs. Jinn beliefs are not only part of psychosis but also can be part of any other psychiatric disorders or just a cultural belief. Lessons to be learnt from Deena
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Lessons to be learnt from Deena-cont. The role of public education through the media is very important. Both mental health professionals and religious scholars should address such issue jointly in the media. It is essential that scholars and healers receive education in mental health to help in changing misconceptions and superstitions, although this can be controversial.
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Conclusion-1 The presentation of these three cases as presented to daily practice in Amman –Jordan, an Arab Muslim community, shows clearly the need for mental health professionals to take in to consideration the religious and spiritual background of the patient in diagnosis and management,
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Conclusion-2 The mental health professionals need to be educated in the true Islamic teaching and the prevailing malpractices and false concepts and whether they are accepted or not. Ethically, if the professional cannot manage a case because of its religious and spiritual complications, he should refer the patient to another professional
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References Stein, M. (2011), Faith and the practicing analyst. Journal of Analytical Psychology, 56: 397–406. doi: 10.1111/j.1468-5922.2011.01916.x. Magic, jinn and envy -1998-2011 islamweb.net. Somayya Abdullah -Islamic Counseling& Psychotherapy Trends in Theory Development, Zeriislam.com nukqëndrondomosdoshmërisht pas çdotekstitëautorëve – Copyright © ZeriIslam 2005-2009. Alean Al-Krenawi and John R. Graham Culturally Sensitive Social Work Practice with Arab Clients in Mental Health Settings: February 2000 –national association of social workers-NASW. Peter J. Verhagen, Herman M. van Praag, Juan J. López-lbor Jr., John L. Cox and Driss Moussaoui--Religion and psychiatry: beyond boundaries Book -World psychiatric association 2010. Mawan A. Dwairy: counseling and psychotherapy with Arabs and Muslims. Published by Teachers College press, 2006. ISBN 13: 978-0-8077-4700-1 Amsterdam Avenue, New York, NY 1007 -206. Marwan A. Dwairy: Cross- cultural counseling-the Arab -Palestinian case ISBN 0-7890-0481-X -2007 Haworth Press, Inc.10 Alice Street, Binghamton, NY 13904-1580
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