Monday, June 11, 2007

Can the psychotherapy of Muslim patients be of real help to Them Without being Islamimized?

Can the psychotherapy of Muslim patients be of real help to Them Without being Islamimized?
By: Malik B. Badri
The impossible task of precisely defining psychotherapy
Though psychotherapy is as old as human existence, as a modern profession it has only evolved over the last 100 years. Because of the conflicting theories and paradigms behind the specific techniques used by different perspectives, psychotherapy cannot be precisely defined. There are those who, like a horse with tight eye-blinders, can only view psychotherapy through the tunnel vision of their particular school, and those who open the doors of psychotherapy to include almost all forms of treatment and goodwill towards the,patient. An example of the first group is clearly seen in the definitions offered by psychoanalysts who consider any form of psychological treatment that does not deal with resolving the alleged unconscious complexes as a waste of time and effort. The second group is presented by psychiatrists like English and Finch (1954) who define psychotherapy as, "...almost any method utilized to alleviate or remove the results of emotional conflict and improve psychic adjustment".
As a result of this confusion, the field of psychological therapy and counseling has become an arena for all sorts of fads and crazes. In editing a handbook of psychotherapy, Richie and Herink (1980) found themselves compelled to limit the number of different therapies to about 250! In going through their handbook one will find that there is probably not even one aspect on which all therapists agree on. As Harper (1965) says:
"There is scarcely a psychotherapeutic theory or technique endorsed today by some reputable therapists which has not been skeptically viewed or seriously questioned by others."
As a reaction to this confusion regarding the nature of psychotherapy, Raimy, as early as 1950, came up with the facetious definition that psychotherapy cannot be defined except as, "an unidentified technique applied to unspecified problems with unpredictable outcomes". A more modern equally interesting definition is that psychotherapy is what psychotherapists do!
The Psychotherapist as a warm accepting friend
If psychotherapy is what psychotherapists do, then it would indeed be justifiable for us to ask, "What do they really do?" As the popular stereotype shows them, they are warm, accepting and empathic good listener to their patients. Indeed this is the most portrayed image of the psychotherapist. Of course being a friendly listener and offering wise advice to people with problems is as old as human existence on this earth. It was universally accepted since ancient times as one of the major factors that help to heal psychological wounds. People in distress would naturally seek the help of their sincere friends or gurus or elders to counsel them and relieve their psychological suffering.
In our modern time the psychologist who is credited for advocating this most important role of the psychotherapist is Carl Rogers who in many of his publications on his psychotherapeutic technique known as the person-centered therapy stipulated that the counselor should first be a real genuine person and should unconditionally accept the client without judging or evaluating him. Furthermore, he should always be warm and empathic and he should not directly tell his client what to do or not to do in order to solve his problem or actualize himself but to indirectly guide him to take his own decisions.
But though it certainly helped in making psychotherapy a more humane and friendly endeavor, Rogerian counseling has been criticized for being contradictory in telling the therapist to be genuine and at the same time to be unconditionally accepting to his client. No one can have a genuine inartificial social relationship with any one without being judgmental. As normal people with genuine feelings we are all the time making judgments about other people. This is particularly so in societies where moral and religious teachings are highly valued.
Secondly, if the therapist refuses to interfere in directing his clients about what is good or not good for them as is usually the case with such counselors, they would often feel confused. As Martin Seager puts it:
"Many clients (of person centered counseling) feel lost and confused. They often lack a clear sense of identity and self. They themselves cannot be 'client-centered' because they don't have any sense of where their centre is, (The Psychologist, August, 2003 issue, Vo116, No.8).
If this is what is happening to British patients in secular Europe o f the year 2003, it is no surprise to find that this kind of "nonjudgmental unconditional acceptance" gre~ failing in Muslim countries.
Thirdly, it was questioned whether being warm and friendly and psychologically helpful to people really needs all the years of training that psychotherapistsago,th~ough and whether in this matter there is any difference between a psychotherapist and a lay person. In his well documented book, Against therapy, Dr. Jeffery Masson writes in a section indicatively titled, "The myth of training" of psychotherapists in the following mocking manner:
"Therapists usually boast of their 'expertise,' the 'elaborate training' they have undergone. When discussing competence, one often hears phrases like 'he has been well trained,' or 'he has had specialized training.' People are rather vague about the nature of psychotherapy training, and therapists rarely encourage their patients to ask in any detail. They don't for a good reason: often their training is very modest (1988, p.248)
This skeptic approach has led many contemporary experts to state that an untrained sincere friend can be as good as or at times even better than a trained therapist. Some scholars have even advised clients to avoid psychotherapists who are highly trained and who have long letters after their nam s. Their outlook would be narrowed down to their restricted specialization, wondering where to pigeonhole the patient from his 'symptoms' by the help of the Diagnostic and Statistical Manual of Mental Disorders rather than simply seeing him as a person with a psychic problem. A friend who has been through a similar problem as the client and who has since recovered from it would be a much better therapist.
To empirically test this claim, a number of studies have been carried out to compare professional "psychotherapy" with discussing one's problems with a friend. The results were almost always "No difference, between the lay therapists, and the trained counselors". One such study was carried out at the Vanderbilt University. Young men with various neurotic disorders were assigned to one of two groups of therapists. The first group was made up from leading psychotherapists who have completed an average of 23 years of experience while the second group consisted of college professors with unrelated academic specializations but who have earned the reputations of being warm and good people to talk to. Both groups had about 25 contact hours with their clients. The results came up with the expected outcome of no difference between the two groups. The tests showed that both groups improved but there was no difference between them. (Bernie Zilbergeld, 1986).
By stating these views, I am definitely not saying that modern training in counseling and psychotherapy is a useless endeavor. I simply want to affirm two things: Firstly, that training in counsel and „psy_chotl_erapy_, is like teacher-training. A good teacher has both inborn qualities plus good training. Many excellent teachers have had no training in their field, but they possess the talent of simplifying their subject matter and making it very interesting to their students. On the other hand a lot of highly trained teachers with many letters after their names simply bore their students and fail to motivate them. Obviously, this fact would not stamp the science of teacher¬training as an ineffective practice and no wise person would call for declaring the discipline a useless endeavor. When applicants apply for a teaching job, it is only sensible for the school to choose the one who was trained; the probability that he would do a better job than the untrained teacher clearly out ways the contrary. Similarly we expect the trained counselor to do better than the untrained person though we may often be surprised to find that he doesn't. My second point is a consequent of the first. Bearing what I said in mind, counselors and psychotherapists should develop the humility to see themselves and their training for what it is. They are not being taught in skills like those of surgery in which a person is either trained as a surgeon and can operate or he is not and should stay away from the profession. They are simply instructed in giving better help to people with problems, an enterprise that everybody else is doing without their sophisticated apprenticeship. Some have natural qualities to be good therapists without being specialized.
We have thus far been discussing the role of the psychotherapist as a warm understanding good listening friend. This is one of the few areas that have a clear consensus among modern psychotherapists. But isn't it really surprising that it took modern psychotherapy that long to come up with therapeutic practices that humans have been successfully applying since antiquity. It is more than a hundred years since Freud established psychotherapy as a specialty in his psychoanalytic school, while Carl Rogers developed his complete theory and therapeutic techniques of client-centered therapy as late as 1959.
What is the reason for this delay? The main reason is that psychotherapy as a branch of psychology has alienated itself from being a humane endeavor of helping those who suffer from psychological problems to an artificial replica modeled after exact sciences and medicine. Ironically it was Freud himself, the very founder of this field, who, by adopting a medical model to the etiology and treatment of the neuroses, has neglected the obvious colnmonsense fact that psychotherapy is a process of learning and education in a friendly ~m~iance. Furthermore, with his indefatigable effort to establish psychoanalysis as the uncontested science of psychological therapy, he was able to establish an association of devoted, mainly Jewish scholars and scientists who had themselves been psychoanalyzed and 'brainwashed' into accepting the pseudo-scientific claims of their profession as authentic science. Thus psychoanalytic theories have become an immense system of a psycho-philosophical edifice that influenced all forms of disciplines from medicine, sociology and anthropology to political science, art, literature, economics, religion and other fields of information.
Accordingly, it was only after the decline and fall of the Freudian empire and its psychodynamic offshoots that psychotherapy regained its rightful down-to-earth role as the practice of helping the emotionally disordered to unlearn their pathological habits and thinking patterns and develop new ways of healthy adjustment without wasting time in 'uncovering' unconscious sexual complexes or digging up trivial experiences of early childhood. Before discussing the vital endeavor of Islamizing psychotherapy, it may be more useful to give the reader a more detailed but simplified exposition about the long journey of this discipline from Freudian psycho-dynamism through behaviorism to cognition and finally to the shy emergence of spiritualism.
Freud and his medical model
Freud viewed all neurotic and emotionally disordered symptoms as the visible upshots of largely sexual and aggressive unconscious conflicts or complexes. This was so because he viewed all human activities as motivated by libidinal sexual instincts and aggression, either in a clear or symbolic manner. Emotional disorder is caused by supposed mainly sexual unconscious conflicts largely repressed during the early childhood of the patient. Accordingly, the treatment of psychological disorders in psychoanalysis should not be directed towards the symptoms themselves but to the underlying unconscious dynamics which caused them. Consequent to this view, trying to relieve the disorder by direct symptomatic treatment will not succeed, and if it temporarily does, it will definitely be followed by other symptoms which may be more serious in nature. This is what is known as the medical model of psychotherapy which ruled over the field for more than 70 years.
Let me simplify this to the lay readers. Since Freud was a medical practitioner, he perceived psychological symptoms in terms of physical symptoms. If one presents to a doctor with high fever and headache, he would not simply treat the symptoms directly by giving aspirins or painkillers. Instead he would look for the 'underlying' indiscernible causes of these complaints. He would ask for an X-ray, blood or urine test or some other tests to help him make the correct diagnosis and then he would prescribe the medicine to attack the unseen causes and not the symptoms themselves. Once the microbe has been detected, the right antibiotic will deal with it and the symptoms will automatically disappear.
Similarly, the psychoanalytically oriented therapist would not deal with the anxiety, phobias, depression or obsessional disorder of the patient directly but work to uncover the unconscious complexes that had caused them by techniques such as the interpretation of the symptoms and their 'real' hidden meanings, free association, in which the patient relaxes and says whatever comes into his head, and dream analysis. Once these conflicts become conscious and the patient relives his ordeal through transference, in which the patient is supposed to project attitudes and emotions he had towards parents or important people in his life onto the therapist, he is supposed to get over his symptoms.
Just as fever and headache can be caused by a host of illnesses, anxiety, phobias and other psychological symptoms can be the result of different kinds of conflicts. But to try relieving the psychological symptoms directly one would be like the fellow who tries to close the mouth of a volcano by rocks and reinforced concrete. Even if he succeeds in this impossible hypothetical illustration, the boiling lava in the "unconscious" of the mountain will increase in pressure until a new volcano irrupts in another weak side of the mountain. This is what is meant by "symptom substitution".
In physical medicine, physical symptoms like headache and fever are useful in telling us that something is wrong and that a battle is being waged by our immune system against the invading bacteria. According to the medical model of Freudian psychoanalysis, psychological symptoms are also adaptive in nature. They are also supposed to tell us that an internal battle is being fougl~t between our id unconscious sexual and aggressive instinctual impulses which discharge energy for immediate satisfaction (cathexis) and the antagonistic defensive energy of our ego which blocks this animalistic drive since it does not agree with social and moral norms (anticathexis).
This psychoanalytic model is obviously fascinating, but what is fascinating and interesting is not necessarily true! As a therapy, it was found to be generally as good as no therapy at all! Not only that, but a number of researchers have concluded that in some cases receiving psychoanalytic therapy may even do more harm than good to the patient. At times, if a patient is made to remember very painful and embarrassing experiences of his childhood such as being raped, his condition may actually c~eteriorate. A famous British psychiatrist who had been a member of te British Psychoanalytic Association for many years, resigned after discovering the serious flaws in its theory and practice and the harm that psychoanalysis can sometimes do to patients. She wrote an article in the sixties in The British Journal of Psychiatry, indicatively titled, "Psychotherapy for patients treated by psychoanalysis". She was treating them from the treatment they had received at the hands of psychoanalysts! It is unfortunate that l have lost the reference.
In criticizing this medical approach, Tom Rusk, in his best-selling book, Instead of therapy says:
"Although I am a psychiatrist, and therefore a medical doctor, I no longer believe that the language of science and medicine applies to the work that I do with my clients. I am one of the growing number of psychological counselors who believe that psychological healing did not ever belong in the realm of medicine.
The focus of all counseling is on helping us learn to change our relationships with ourselves and others. I believe this kind of learning is really no different from any other deliberate learning" (1997, p. xiv),
The rise of behavior therapy
Though different researchers like Watson and Rayner in 1920 and Mary Cover Jones in 1924 have clearly shown that neurotic symptoms can be initiated or cured in the laboratory by experimental techniques based on learning by conditioning or by 'deconditioning', thus experimentally refuting the established Freudian claim of unconscious conflicts as the cause of neuroses, it remained for Eysenck in 1952 to empirically expose the inefficacy of psychoanalytic therapy. In his now historic research, Eysenck compared an experimental group of neurotic patients who were admitted to British hospitals for treatment by psychoanalytically oriented therapies with a carefully matched control group of similar patients who could not find beds in the hospitals and who accordingly received no therapy. After one year, Eysenck found about two¬thirds of the treated group have improved. He was astonished to find that the same proportion of the untreated control group have also improved! The publication of this study was literally like an exploding bomb in the face of psychoanalysts who retaliated with all sorts of "conscious" and "unconscious" defenses but their battle was eventually lost since many experimenters who repeated Eysenck's study came up with similar results.
Eysenck has thus paved the way for Wolpe the founder of behavior therapy. Since 1947, Wolpe was doing experimental studies with cats in his laboratory in South Africa to prove that neurotic symptoms were actually maladaptive learned habits acquired by conditioning and that they can be treated by a process of 'rewarding' in the gradual presentation of the feared object. This led him to lay the foundations of behavior therapy and to pioneer his distinguished work in his classic textbook, psychotherapy by reciprocal inhibition (1958). In this book Wolpe introduced behavior therapy as an explicitly formulated highly successful alternative to the defeated psychoanalytic therapy.
For the first time in almost 70 years, Western psychologists started to abandon the useless search for trivial unconscious conflicts to attack the symptoms of emotional disorder in a direct manner and to use a simple learning theory approach in diagnosing and treating neuroses. Many patients, particularly those suffering from phobic anxieties, sexual disorders and obsessional neuroses, who wasted years of their lives and much of their savings in fruitless Freudian analysis, have been cured or greatly improved after a few weeks of behavior therapy.
The main tenets of this new therapy are that we learn our neurotic symptoms in the same way that we learn useful habits. We learn to fear snakes and this is an adaptive habit but we can also learn to fear parties and social situations, lifts or cockroaches and these are maladaptive habits. There is no deep-down unconscious cause for either the adaptive or the maladaptive habits. Both are the outcome of learning by conditioning. If you decondition the 'bad' habit by unlearning, extinction or reciprocal inhibition you have treated the neurosis. Once cured, no other symptom will appear in its place, but on the contrary, it was found that treating one neurotic symptom often results in the improvement in other symptoms that were not treated.
For example I have known patients who suffered from a phobia and reactive depression. When the phobia was cured, the depression disappeared. Since psychological symptoms are rarely related to deep-rooted unconscious etiology, one would logically expect the depression to improve because it must have been wholly or partly caused by the incapacitating phobia. Similarly a patient referred to us in the Department of Psychiatry of the Middlesex Hospital Medical School who complained from social anxiety and non-assertiveness together with sexual impotence, was surprised to find himself sexually normal with his wife after behavior therapy made him assertive. The relationship between the two complaints is obvious.
Let me say a few words about conditioning and reciprocal inhibition to those who are not familiar with them; psychologists either bear with me or skip this section. We learn habits by classical Pavlovian conditioning when a'natural' or unconditioned stimulus which reflexively elicits an involuntary unconditioned response e.g. salivation to food as in Pavlov's dogs, is associated with another neutral or conditioned stimulus e.g., the bell in Pavlov's study, until the organism learns to respond to the new neutral stimulus in the same way as the 'natural' stimulus i.e. the dog learns to salivate to the sound of the bell. In the experiment done by Watson a baby was made to develop conditioned fear of a white rat (conditioned stimulus) when the experimenter sounded a big terrifying bang (unconditioned stimulus) whenever the baby touched the rat. The baby naturally responded with terror (unconditioned response) and eventually learned to fear rats (conditioned response). So in a behavioral therapeutic paradigm the symptom is always a learned conditioned response.
And when we learn habits by the other form of conditioning espoused by Skinner, instrumental conditioning, we first have to do some voluntary action. If this is immediately followed by a reward or positive reinforcement, it will be repeated more frequently in future and if on the other hand it was followed by a painful stimulus and we stop doing it and consequently relieve ourselves from the painful stimulation, (negative reinforcement) the repetition of this act will be less in future.
If we want to get rid of a neurotic symptom which causes us anxiety we should stop its association with the original stimulus, i.e., in Watson's experiment, we repeatedly bring the rat to the baby without any more banging or terrifying noise. This is known as extinction and it is not generally very helpful in such highly fearful stimuli. Reciprocal inhibition or treatment by the opposite is the symptomatic treatment of choice in such cases.
I can give the reader a concrete example from a very rare case of obsessive-compulsive disorder that I treated last year in the clinic of the Health Center of Dewan Bandaraya in Cheras, Kuala Lumpur. The patient, a male janitor in a Government building, cannot resist the compulsion of taking a shower and changing his clothes whenever he smells certain offensive odors. These were mainly old fish and to a lesser extent, the smell of decomposing dead rats and similar bad smells he encounters in his work as a cleaner or in the street. After a few sessions of cognitive therapy and relaxation, I brought into the clinic a plastic bag containing a dead decaying fish and a bottle of concentrated perfume. The patient would smell the fish until his anxiety mounts and the overpowering compulsion to wash has overwhelmed him; then he would quickly take deep smells from the perfume until the anxiety provoking smell of the fish is diminished. With cognitive support and encouragement he was able to increase the time of smelling the bad odor. He reported much improvement after these sessions. He reported that he wouldtake a small bottle of perfume in his pocket to use if the compulsion returns. In this case the perfume is opposed to the bad odor and the relaxation and cognitive therapy would bring responses contrary to anxiety.
This reciprocal inhibition method has been developed by Wolpe into psychotherapy's most successful technique by using the ability of the patient to imagine and by presenting the anxiety provoking stimuli in a gradual fashion. These are the techniques known as systematic desensitization and that of practical retraining. People phobic of animals and insects, for example, can first look at them as dead and small in size at a far away distance and gradually brought nearer and nearer to them as they are presented live and bigger in every consecutive session. When the noxious stimulus cannot be brought into the clinic or when the therapist prefers to use 'imaginal' desensitization, the patient is asked to imagine the feared or noxious situation in the graded fashion designed by him and his behavior therapist and while reclining or lying in full relaxation in the clinic he imagines himself dealing with the least anxiety-provoking scenes and gradually going up the hierarchy to the most difficult ones. For instance patients who suffer from social fear and anxiety with authoritative adults can be trained when relaxed to imagine themselves mixing only with children and gradually the age and number of people is raised until they achieve the ability to transfer the learning of the clinic to real life situations.
However, some behavior therapists have challenged this gradual approach by exposing patients from the start to prolonged sessions involving the most intense anxiety-eliciting situations, in the hope that, by finding no way out of facing their feared object, as they generally do in real life, they would learn to anticipate that there is no real catastrophe in facing it; in everyday language, they would get used to it. This technique is indicatively named "flooding". Though some claim that it is very successful in the treatment of generalized anxiety in a much shorter time, long-term comparisons have shown the superiority of gradual systematic desensitization.
When the patient presents with symptoms that are pleasurable to him but he wants to get rid of them such as taking alcohol, drugs, or unacceptable sexual behavior, symptomatic treatment by reciprocal inhibition would necessitate the use of opposite painful stimulation while the patient actually takes or imagines that he is doing the pleasurable unwanted act. Therapists use electric shocks to the arm, shaming, flagellation with a rubber band, offensive smells, chemicals that induce nausea and other painful stimuli in the hope that the once pleasurable response will be associated with this these very painful punishments. This aversive therapy was found to be successful with all kinds of addictions and sexual disorders. Some therapists have even used it with obsessive compulsive disordered patients.
On the other hand if the therapist wishes to use positive reinforcement according to Skinnarian instrumental conditioning, he can quickly reward the patient whenever he does what he is supposed to do, for example refusing to eat chocolate for an obese person or spitting out a mouthful of an alcoholic beverage for an addict. If what is to be done is complex such as cleaning himself and making his bed if he were mentally subnormal then the therapist should "shape" it like a coach teaching an athlete or an expert training a falcon to catch a prey. He first gives a reward for achieving a simple task and then gradually the reinforcement is given only to more advanced skills until the complex behavior is completed. The therapist works like a coach training an athlete in high jump. First the bar is placed in a low position and gradually raised as he learns to perfect his skill.
I have devoted these pages to acquaint the reader with the second agreed upon role of modern psychotherapy in helping people with emotional problems. It is that of helping the disordered to change their pathological emotional habits or external behavior. Though, as stated earlier, there is much confusion as to what psychological therapy is, there is general consensus among psychologists that these techniques of behavior modification are among the most beneficial and efficacious methods of the field since their effectiveness has been empirically confirmed. In fact, most early behavior therapists were so proud of their achievements that they did not use the term "psychotherapy" to describe their specialty. They thought of themselves as scientists of specified techniques of behavior change that should not be mixed up with unscientific psychoanalytic and psychodynamic perspectives or loosely defined person-centered counseling. They speak and write about two separate areas in treating psychologically disordered people: psychotherapy and behavior therapy.
The cognitive revolution
Paradoxically, it was this strong determination to emulate an outdated paradigm of physics that brought about the revolutionary paradigm shift known as the cognitive revolution. In their zest to limit the field of psychological research to the objectively measurable forms of behavior, classical behaviorists refused to accept the so-called 'subjective' aspects such as mind, consciousness and other cognitive processes. To them, these were not worthy of scientific investigation. In 1929, Watson, the father of behaviorism, stated that consciousness, "...has never been seen, touched, smelled, tasted, or moved. It is a plain assumption just as unmovable as the old concept of soul" (Marx & Hillix, 1979, p.138). This position was strongly supported by Eysenck 43 years later when he argued that, "If you wish to postulate a mind, or a soul, or even consciousness, you are of course free to do so; all that the psychologist (or behaviorist) says is that these concepts do not enter into his formulae" (1972, p. 304). In his much quoted witty criticism of behavioral psychology, the late renowned British psychologist, Sir Cyril Burt, is quoted to have said, "modern psychology, having first bargained away its soul and then gone out of its mind, seems now, as it faces an untimely end, to have lost all consciousness " (Eysenck, 1972, p. 300, italics ours). Western psychology regains its mind and consciousness:
This extreme position is one of the main reasons for the rise of the "cognitive revolution" and the return of the mind and consciousness to Western psychology. Cognitive psychologists refuse to limit their role of studying emotional reactions as simply responses to external or internal stimuli that can be measured and manipulated while neglecting what goes on within the thinking mind of the responder, calling it "a black box" that cannot be deciphered. Conversely, the cognitive perspective view emotions as entirety a direct consequence of the way one looks at stimulating life events. It is not the stimulus by itself that directly brings about the response, as behaviorists like to believe, but more importantly the way the person views this stimulus. Thus one cannot experience an emotion before processing it. We must first understand an experience before feeling it, and feeling must be preceded by conscious thinking. Normal thinking gives normal emotions and pathological thinking begets pathological emotions. Man has a continuous dialogue with himself and the thoughts that cause emotions are often fleeting and swift but specific and discrete. Beck, (1976) calls them automatic thoughts. These thoughts if unchecked can develop into strong emotions and can motivate actual neurotic behavior. That is why cognitive therapists train their patients to catch the "culprit" or the cognitions and thoughts that just precede the disordered emotion.
To cognitive therapists, neurotic emotional reactions are generally generated by irrational thoughts. So an important aim of cognitive therapy is for the therapist to help the patient to use his problem solving and unbiased observation to consciously challenge and change his inner thoughts. In other words, to change the software in his mind! Once the inner conscious cognitions have been changed, the sick emotions will find no support and will eventually disappear. Consequently, the external behavior will also be normalized. Burns (1980) gives a very amusing illustration to the fact that emotions simply follow the way we think, whether we think logically or illogically. He writes, "Your emotions follow your thinking just as surely as baby ducks follow their mothers. But the fact that a baby duck follows faithfully doesn't prove that the mother knows where she is going!" (p.46).
This cognitive approach was influenced by the computer revolution. From a Pepsi Cola vending machine of stimulus-response behaviorism man is viewed as a processor of information. If man were to be a real computer, then the environmental events would act as strikes of selected keys in the 'keyboard' and his internal cognitive activity, like thinking and feelings, would act as the software or program which the "internal processing unit' uses to send out coded information to the "monitor". Thus two persons with different 'softwares' in their brains or minds will respond differently to the same environmental conditions, just as the same keys struck in two computers with different softwares will bring about different material in their monitors.
We have now given a simplified exposition of Western psychotherapy, showing the three beneficial areas on which psychotherapists have a general consensus. These are: the role of the psychotherapist as a warm accepting good listening friend, his role as a behavior therapist helping patients to unlearn their pathological habits and his role as a cognitive therapist helping the emotionally disordered to consciously change their thinking and the cognitive aspects that support and motivate their emotional symptoms. By completing this section of the paper we come to discuss our main objective of the Islamization of psychotherapy.
The Islamization of Psychotherapy: An introductory statement
The Islamization of Western secular therapeutic techniques is so vital that one really wonders why it was not done decades ago. This is so because there are special disorders that cannot be treated without going into religious or local cultural issues. I can give a few examples. Epidemiological studies in many countries have shown that phobias or irrational fears are the most common anxiety disorders. Many Muslim patients complain of incapacitating phobias of death, disease or jinn. I often wondered how a therapist can succeed in treating such phobias in a Muslim patient without an in-depth cognitive intervention regarding the teachings of Islam about jinn, life, death and life after death. Without changing the irrational beliefs of a patient concerning these spiritual issues, no secular therapy can be of real help for him or her. In my long experience of almost forty years I have always found that whenever I applied an Islamically oriented psychotherapy, my patients who had previously failed to benefit from drugs and secular psychotherapeutic interventions, were simply cured or greatly improved in a short time.
On the other hand I also found many of my colleagues unable to help clients with marital problems because of their ignorance about Islamic family law and the Islamic teachings concerning sex, inheritance, divorce, and the custody and guardianship of children. This Islamic knowledge is vital particularly to women who greatly outnumber men in seeking the help of therapists. In our modern Islamic countries, women are generally deprived from their rights because of their ignorance about these rights. They may seek the help of a psychotherapist because they developed unwarranted guilt and anxiety as a result of their failure to cope with the unjust demands that men level against them. For example, many women develop serious anxiety and guilt because after their fulltime overwork in their offices they find themselves compelled to meet the uncompromising demands of their husbands. These good Muslim women are unaware that cooking, washing and other domestic chores are not required from them according to Islamic jurisprudence. They can volunteer to do them if they wish, but it is not Islamically mandatory.
Husbands, out of tradition and lack of knowledge believe that it is their Islamic right to be served whether the wife is too tired to do so or not. Because of this ignorance about the rights of wives they often misuse religious quotations to make their exhausted wives guilty. In fact it is the Islamic responsibility of the husband to provide for such help. If he cannot, he should be grateful to his wife if she volunteers to carry out these services rather than blaming her. Many Muslim therapists are also uninformed about these religious facts and so they often exacerbate their female patients' guilt by their misdirected therapy. I have found that just by knowing these Islamic teachings, a number of wives who consulted me have lost much of their guilt and with this new spirit they actually continued to give the same services they were grumbling about with enhanced spiritual acceptance of religion. Not only that, but the Holy Qur'an has explicitly stated that it is not mandatory for a mother to nurse her own newly born baby if problems break out between her and her husband. In Surat al-Talaq the Noble Qur'an says that if the married couple is at odds concerning their married life, the husband should either pay the wife for nursing their baby or hire another woman to nurse it. Not only that, but in many Muslim African countries, women are not given what they deserve in terms of inheritance. If the psychotherapist or counselor is himself ignorant about these Islamic teachings, how can he be of help with such problems?
Furthermore, therapists helping patients with debilitating guilt concerning what they view as terrible sins they had committed such as drug and alcohol intake or deviant sexual behavior like homosexuality would generally fail to help if they follow the secular psychotherapeutic techniques they studied in the West. There, they are told to be neutral and nonjudgmental and not to bring religious issues in their therapy. Here, if Islamic issues are not discussed in a warm friendly optimistic manner the patient may never improve.
Islam as a religion and a worldview has a much greater influence over Muslims than any other religion or worldview. That is why an Islamically oriented psychospiritual therapy can even help hardened drug and alcohol dependents whom modern western therapy consider as totally hopeless since they fail to get benefit from medical and psychological interventions. One of my popular stories in this connection concerns an honest broad-minded European psychiatrist, Dr. Karl Schmidt, who was practicing in Brunei. He read a valuable paper on his innovated techniques of treating drug and alcohol addicts in Brunei. The paper was read in Amman, Jordan, in 1987 in the Third Pan Arab Congress on Psychiatry sponsored by the Association of Arab Psychiatrists. He took a group of addicts to a camp outside the city and subjected them to a daily rigorous program heavily saturated with Islamic activities involving prayers, talks and video shows, and physical training accompanied by the chanting of Islamic slogans. The program started from dawn fajr prayers to bed time. The result was fantastic. The relapse rate of treated addicts was more than 90% with the secular methods. It fell to about 65% with the Islamically oriented therapy.
Indeed, after seeing many such alcohol and drug dependent patients, I have come to the conviction that unless the excessive guilt concerning their committing to such sins is dealt with through an optimistic approach stressing God's Mercy and forgiveness to all sins, they may lose hope of being accepted by God and hence indulge in their harmful habits of extravagant alcohol and drug intake either to relieve their stress or simply to enjoy their addiction since no treatment is helpful and anyway, according to them, God has already stamped them as evil. The secular approach of viewing religion as irrelevant or something to be avoided can thus be of no help or even harmful to such patients.
Since psychotherapy is supposed to be an educational endeavor, it should be based on the worldview and the culture of those seeking its help. Even European psychologists and psychotherapists are beginning to grumble about the hegemony of American psychology. They say that America is the superpower of psychology and that their students are being psychologically Americanized as they study psychology from American texts that flood their markets. Many Western psychologists are beginning to realize that their field is largely culture bound and mainly influenced by American psychology and its emphasis on extrapolating from animal studies and its use of American students as subjects. Listen for example to the well-known British psychologist Eysenck as he writes in 1995 in the journal of World psychology (Vo.1, No.4, p.13):
"Much of our psychology is based on studies of American college students, rats, pigeons, and mentally abnormal groups...It must be clear that this is not sufficient as a basis for a science claiming universal status."
If even European psychologists are complaining from this Americanization of psychology, though their cultures are identical in most of their major tenets, how can we, Muslim, Asian and Arab psychotherapists continue to counsel and treat our patients as though they were American clients. Our age, as some scholars say is the age of the idolatry of science. Most of our Muslim psychotherapists continue to swallow this ethnocentric psychotherapeutic culture bound stuff simply because they are sugar-coated with 'science'.
It is sad to say that while some of our Muslim therapists cling to their modern school of therapy as if it were a revelation, we find that some honest Western psychologists beginning to see the ethnocentric quality of their specialty and warning about its wholesale exportation to other cultures. For example, in their well written paper titled, "But is it a science? traditional and alternative approaches to social behaviour", one psychologist from Georgetown University, USA, Moghaddam, and a second psychologist from Oxford University, England, Harre', has this to state. I have put this long quotation from their article since it says clearly how our mental slavery to "Americanized" Western psychology can only perpetuate exploitative traditions of colonialism:
"...the most important factor shaping psychology in the international context continues to be power inequalities between and within nations. The inability of psychology to contribute to Third World development arises in large part from these inequalities... and surely this is an unethical issue. Putative psychological "knowledge" which is of highly questionable reliability and validity even in the Western context is being exported wholesale to Third World societies, as part of a large exchange system ultimately driven by profits.
The United States has established itself as the only psychology Superpower...Psychology continues to be exported from the U.S. to the rest of the world, with little or no serious attention given to the appropriateness of what is being exported...Similarly, Third World psychologists are trained in the U.S. and in other Western countries, without regard to the question of the appropriateness of their training. Indeed, the continued exportation... and inappropriately trained personnel from Western to Third World societies strengthens ties of dependency and continues exploitative traditions established through colonialism" (World Psychology,1995, pp. 53-54, italics ours).
It should now be clearly appreciated that without adaptation, some culture-bound forms of Western psychotherapy can be of no use to Muslim clients and can at times be harmful. But does adaptation mean Islamization? Yes, indeed. Though some kinds of adaptations in which psychotherapy is tailored to suit the clients of a particular country may not necessarily stand for Islamization, all forms of Islamizations are indeed adaptations. Western psychology itself asserts that the psychological and the socio-cultural components are the pillars of shaping human personality. Anyone who fails to see the very great influence of Islam as a religion and a way of life in molding the personality of a Muslim is a myopic who suffers from tunnel vision.
The main attribute or trait that gives the average Muslim client his uniqueness is his religion. Faith in Allah Ta'ala as the Almighty Creator and Sustainer of this universe and His knowledge about the secrets in the hearts of men and that which is beneath their secrets (subconscious) "~s}I 9;--JI ` 1~ *, " and that whatever happens to man in this world is already destined and has a Divine Wisdom behind it. The belief that there is life after this life and man has a free will and is accountable for whatever he had done during his brief stay on earth. These beliefs would make it necessary for any psychotherapist working with Muslim clients to Islamize his work even if he were not a Muslim himself. All the major perspectives of Western psychotherapy deny the soul. They treat man as though he were a talking animal. The terms "God", "soul", "spirit" or "good and evil" are out of bounds irrespective of whether the perspective is behavioristic, psychoanalytic, humanistic, biological or cognitive. They are all erected on a secular worldview.
I firmly believe that because of their rejection to the secular approach of Western trained therapists, most lay Muslim patients, particularly in rural areas are reluctant to be referred to modern psychiatrists and counselors. They would however be glad to be seen by traditional and religious healers. I have found this in a research study that I presented to the Traditional Medical Practices Committee of the World Health Organization in Geneva (Badri,, 1978). In all the Islamic countries I have studied, I found that the great majority of neurotic patients go to traditional healers. Though they deprive themselves from the modern psychotherapeutic techniques and subject themselves to harmful interventions by the quacks and imposters who pose as religious healers, they may get much benefit from the suggestive and spiritual help that are not available in modern clinics and counseling centers. They are ready to take these risks because they yearn for the spiritual explanations and therapy offered in traditional healing.
After this long introduction, let us go into some detail concerning the role of the Islamically oriented psychotherapist with respect to the three helpful areas on which there is a general consensus among psychotherapists. These, as I delineated, are: the role of the psychotherapist as a warm accepting good listening friend, his role as a behavior therapist and his role as a cognitive therapist.
The Muslim psychotherapist as a counseling psychologist The therapist as a warm accepting friend:
In this section, I wish to discuss the influence of Rogerian Client-Centered therapy and similar perspectives that influenced modern Muslim therapists and to show that its main merits are in fact teachings of Islam and its demerits an influence of secular western modernity that the Muslim therapist should reject. Since this perspective, unlike behavior therapy is rather saggy and too broad to lay down, I shall give it a large space in this paper.
A scholar studying this psychotherapeutic perspective can write volume upon volume to give its pertinent details from the Holy Qur'an, the Sunnah of the Blessed Prophet (PBUH) and the works of our early Muslim theologians, physicians and scholars. These teachings of being warm, friendly and accepting are so obvious that we do not need to spend much time and space over them. In the personality and life of our Prophet Muhammad, the Messenger of Allah (PBUH), modern Muslim psychotherapists can find the highest values and teachings about how to be friendly brothers or sisters to their clients and patients. Just one Verse from the Holy Qur'an is enough to summarize this whole field of Islamic counseling and exhibits its uniqueness. The Holy Qur'an Describes the character of the Prophet in dealing with his followers in these beautiful words:
"It is from the Mercy of God that you deal gently (and warmly) with them (his followers). But if you were severe and harsh-hearted, they would have broken away from you. So pass over their faults and pray for their forgiveness and consult them in affairs before taking a decision and when you decide put your trust on God for God loves those who put their trust on Him (Surat Alimran, Verse No. 159)".
What are the general principles that can be inferred from this single Verse of the Noble Qur'an. They are:
a. Be genuinely warm loving and gentle to your clients. You are not to be a detached empathic or even sympathetic observer as western counseling would suggest but a merciful involved brother or sister. Mercy is more comprehensive and spiritual. It gets its source from the Mercy of God Hi myself.
b. Be accepting and pass over their faults without being nonjudgmental. AS the Qur'an States in another Verse (28:87), "Call to the way of your Lord with fair exhortation, and reason with them in the best manner".
c. The counseling or psychotherapeutic session is a consultative venture in which the therapist does not act as an oppressive leader. So be humble and do not be authoritative. Let your advice come after consultation with the client.
d. The counseling or psychotherapeutic session is a spiritual endeavor in which the therapist or counselor is blessed by God in being selected to help a brother or sister to overcome an ordeal. So you should put your trust in God and should be grateful to Him for Giving you this opportunity.
What more do we need to add to this? We can only give more concrete examples from the sayings of the Prophet and his companions and the writings of early scholars. These scholars of Islam took the teachings of the Prophet and his deeds as the guide for their writings on being warm and accepting to others and on advising them by following the gentlest manner and strictly guarding their secrets. Listen for example to the following sayings or Ahadith of the Prophet:
"Show optimism and make things easy and not difficult and give good tidings and not the news that repel" (authenticated by Muslim).
"He who helps a Muslim to alleviate a hardship of this world, Allah Ta'ala will alleviate for him a hardship in the Hereafter" (authenticated by Muslim).
Influenced by these and similar ahadith and deeds of the Prophet, Abdal Gadir Aljailani writes in his AI-Ghuniah Litalibi Tariq Alhaq what is translated as follows:
"The conditions of good friendship are that you should be forgiving and you should accept whatever your friend says or does and to find an acceptable excuse for anything that does not look right (if it is not clearly contrary to Islamic teachings) (1956, p. 169)".
And as for his advice to the Shaikh or Guru who was actually the counselor or psychotherapist of his time, Jailani says in the same book:
"The sheikh should treat his disciple with mercy and love. If the disciple finds difficulty in changing his bad habits and do what the guru wants, he must be gentle and gradually help him in the way that a mother or a loving father treats their child" (P.168).
Similarly, Abu Hamid Al-Ghazali gives a detailed account on the duties of the Shaikh and his treatment to his disciples. His account can be a very useful guide to modern Muslim counselors and therapists. I am translating some of these duties as follows: "The first duty and attribute of a good sheikh is to be humble and gentle with those he is dealing with. He should not stress on giving knowledge or advising but rather choose the route of mild and tender gradualism. A good sheikh should also be ascetic and should not look at his disciple's money with greed. Another good quality of the guru is that if he comes to see or to know that one of his disciples committed some offense, he should not tell him directly about it. He must be indirect and rather meandering about helping him to see the wrong he had done. He can for example advise a whole group of disciples about the bad effects of what the person had done without making him feel that he is the one meant for the advice. This would be good to the whole group. And finally, the guru should keep the secrets of his disciples and his clients. These people trust him with personal experiences some of which may be embarrassing. The sheikh should put down a heavy lid over his heart and tongue in keeping these secrets in the dark." (AlIhya, Vol.5, P.206-28)
The myth of being totally nonjudgmental: /
It is rather sad to see Muslim therapists who possess such a rich heritage speaking about being trained to be warm and accepting to their clients by experts of Rogerian client-centered counseling. It is as if to be loving, understanding and accepting is a twentieth century discovery by the founder of non-directive counseling. Some of them naively boast about being totally and unconditionally accepting in a value-free nonjudgmental manner. This claim of nonjudgmental value-free attitude is of course a myth. Once you call yourself a counselor or psychotherapist and the one across the table a client or a patient, you have lost your nonjudgmental attribute.
Furthermore, as a humanistic school of psychotherapy, person-centered therapy, as we said earlier, aims at helping the client to actualize himself. But of course this cannot be achieved in a totally value-free way even in the west. The therapist and client will have to follow Western values. A client may wish to actualize himself as a photographer of heterosexual pornographic films and his therapist may say, "That is fine if your choice is the art of filming adults copulating". But no therapist will agree to be value free to the extent of conceding if the client wishes to be a photographer of pedophiles who have sex with children. Such atrocious video cassettes are now thriving in the western sexual industrial revolution. Also, painting is an art which many find self actualizing, but what about an artist who wishes to develop himself in the art of forging counterfeit money or one who would like to accomplish himself by perfecting the fine art of pick pocketing? All such modes of self actualization would not be allowed because they conflict with Western values.
Before I conclude this section I must say that this nonjudgmental approach is actually a symptom of westerners' animosity towards their religion that they have generalized to all other religions. One can understand their position. It is so because they are societies that are haunted by an ugly religious Church history of inquisitions and the burning of hundreds of thousands or even millions of innocent victims; they are societies that have lost much of their faith in their modern religious institutions of the large number of divergent faiths and denominations; societies that were able to scientifically progress only when they discarded religion; societies in which mental health workers are consequently trained to generally view religious persons as suffering from pathological religiosity. In such societies it is understandable that counselors and therapists may be advised to steer away from embarrassing religious topics and to pursue the secularized materialistic path of the overwhelming majority.
Culture-blind aping by Muslim psychotherapists:
What one cannot understand is why our Muslim therapists sheepishly behave in the same secular manner? In the length and breadth of their history, the Muslims have not experienced the moral dictatorship of a church or the barbarous executions of inquisitions. Islam is a simple straightforward rational religion that has an unequaled command over the hearts and minds of its followers. It is a religion in which all Muslims have no shreds of doubt about the Oness or Tawhid of the almighty God, the authenticity of the Holy Qur'an, the Divine message of Prophet Muhammad (PBUH) and other messengers. Just as they all face the same direction to Ka'bah in their daily prayers, they hold to the same worldview and way of life. Even the concept of Divine retribution and punishment is portrayed in Islam in the most optimistic, merciful and rational conceptions. The Holy Qur'an clearly states that God's punishment in this world is meant to ward off more serious future pains and agonies, and to coerce the sinful to repent and secure God's forgiveness:
And indeed We will make them taste of the Penalty (and pain) of this life prior to the supreme Penalty, in order that they may repent and return. ( SuratAssajdah, Verse No. 21)
Also, human anguish is a Divine test to wipe out sins and to elevate the spiritual position of the suffering person. As the Prophet, peace be upon him, said, there is always a reward to the Muslim from God for even the slightest pain he incurs, even if it is the prick of a thorn (Authenticated by Bukhari). These beliefs are deeply rooted in the hearts and minds of average Muslims and if the Muslim therapist does not make use of them in alleviating the psychological agonies of his patients, he would be like the ignorant man in the hot desert who throws away his water because he saw a lake of mirage. Or as the Arab poet describes it, like the camel that dies of thirst while water containers are strapped on its back..
Thus, a Muslim psychologist who rides the western wave of secular therapy is actually selling out his Islamic values and depriving these patients from useful psychospiritual therapy. A loving warm friend may actually be often better than him. This is so I think because the friend humbly sees the emotionally disordered as a person like himself and speaks to him in the simple language of his culture and religion. The trained counselor, as I said, alienates himself by accepting the patterns of a foreign culture as a'science' of psychotherapy!
Islamic psychotherapy requires that the therapist be a Sincere role model and give his clients enough time:
It should therefore be stated that the Muslim psychologist should be aware of the Islamic role that is styled by the spiritual teachings of Islam and the work of early Muslim therapists. He should consider himself a sincere brother or sister or friend and not to be boastful about his specialty. He should concentrate his effort on how to help the Muslim client with his problem rather than how to diagnose him or apply his sophisticated theory and practice on him. He should not be a slave to his specialization or to the stereotyped rituals of western psychotherapy. For example, if he feels that to bring another friend of the patient or his relative or spouse in the therapeutic session would be helpful, he should do so and he should treat them with respect as co¬therapists. If he feels that visiting an old sick authoritative parent of the patient in his house can be therapeutically helpful to the young patient who suffers from his unrealistic control, he should do so.
Furthermore, the clinic or counseling room should not always be a formal strict place of therapist and patient. It can also be a blessed room where the therapist and his client may say their obligatory prayers together or eat and drink and chat together. Also the time taken for treatment should not be the fixed 45 minutes per session as is the case in modern psychotherapy. Quite often traditional healers and sheikhs can do a better job at helping the emotionally disordered because they spend more time with them. Patients get the chance to see the respected spiritually inspired healer as a role model in his social intercourse with others, in his prayers, in his patience with difficult persons and his love and guidance to his disciples. The patients and disciples pray together, eat together and sleep in the same compound.
In a study of traditional healing practices in Sudan that I carried out for a WHO Expert Committee in the eighties, I was astonished to find a number of the patients whom we failed to help in the Khartoum Psychiatric Hospital completely cured or much improved through the traditional Islamic therapy of a famous Sheikh. When I visited his far-off compound to collect information for my research, I was astonished to be greeted by the smiling cheerful faces of the same persons that I had been accustomed to see as perpetually debilitated with chronic anxiety and the sad pessimism of depression.
I know that what I am proposing may not be accepted by modern Muslim psychotherapists who would raise the objection that they do not have the time for such consuming therapy. Some of them would like to stick to the 45-minute session in which they keep glancing at their watches and frequently ending the session just as the patient begins to emotionally loosen up. Traditional Islamic healers find all the time they need for their clients because they also engage in group therapy. They only close their doors with one patient when the latter wishes to reveal personal secrets. That is why I believe that if the patient is not so severely disordered that he needs to be alone with the psychologist, group therapy led by a committed Muslim therapist can often be far superior to stereotyped one-to-one therapeutic sessions. However in a number of cases a combination of both methods can bring about good results.
I think that much informal counseling and psychotherapy of this kind is going on in our Muslim countries. May be for this reason, we find that there are few practicing psychotherapists and counselors. People get free useful counseling from friends, teachers and elderly relatives. As it was once said, "The psychotherapist is an expensive friend but the friend is an inexpensive therapist".
In western countries on the other hand, the materialistic competitive way of life does not give friends and relatives the time or effort to help a friend in need. That is why troubled people there are ready to pay expensively to counselors just to find someone to talk to and to seek his warm relationship even if they know about the research on the limitations of counseling and psychotherapy. Torrey puts this issue in a mocking manner. He says:
"Saying that psychotherapy does not work is like saying that prostitution does not work; those enjoying the benefits of these personal transactions will continue doing so, regardless of what the experts and researchers have to say" (1986, p. 198).
As Muslim therapists we should learn from the traditional healers:
As modest Muslims who are happy to acquire wisdom and knowledge from any source, we should learn from the long pertinent experience of our Muslim traditional healers. The righteous ones among them are the true descendants of Ibni-Sina and Ghazali. Much of what they do with their patients is influenced by the religious traditions of olden days. They know their culture and traditions better than us since their worldview has not been contaminated by modernity and western thought. I have personally learnt much from them and was often amazed by the creative ways they think of to solve the problems of their clients.
I will give the reader a recent example about a Sudanese Sheikh and healer living in a small town about 130 kilometers from the capital city of Khartoum. A disabled partly crippled young beautiful lady in his town used to travel weekly to the Capital to receive physiotherapy in a specialized center run by a German humanitarian organization. A young man working in this center fell in love with her and married her. She moved to his house in the capital. Life went smoothly for a few months after which they often quarreled and he brutally beat her. She would then travel back to her parents, but soon he would come begging her to come back to him and humbly apologizing to her parents and relatives. However, after going back the episode is repeated until in one occasion he was so brutal in hitting her that she needed medical intervention. She came to her parents and vowed not to return to him and asked for a divorce. The parents and uncles were quite happy and relieved by her decision. Village people in Sudan live together as one big family, so everybody knew about her case and supported her demand for divorce. However, after a few months, her physical and psychological wounds healed and she wanted to go back to him even if all her relatives do not support her. This would bring much shame to her parents and elders. It would look as if they do not have any self respect in accepting him after what he had done and that they do not have any control over their daughter, so their prestige in the town would be at stake.
While sitting in the Sheikh's private room, four well-dressed men came to consult him about their dilemma. Their spokesman, the father said, "Please help us out you blessed man. What shall we do to our disabled daughter to prevent this dishonor to us without causing a serious problem to her?" The sheikh paused for some time during which I tried to find a way out of this problem. I have a long experience and sophisticated training, I said to myself, how can I help these worried people and their daughter if they came to me? I could not see any way out. One obvious solution is to say to them, "This is her own life, let her do what she wants and forget your unjustified honor". But this would be a western way of looking at problems. Or may be I would say, "Go to the capital city and convince the husband to divorce her and if he disagrees, threaten to go to the police and sue him for the physical damage he did to their daughter". I failed to think about any other suitable answer. May be the reader can now stop reading for a moment to ask himself or herself for a proposal that helps the wife but does not go against the culture and traditions of the rural Sudanese community and compare it with what the sheikh had done.
After his long pause, the sheikh told them to tell the daughter that from now onwards it is the sheikh himself who would be her father and guardian and her relatives should leave decisions on this and other matters concerning her to him. Because of his high exalted prestige, the relatives were now relieved. They could now say to everybody that our sheikh took over the guardianship of our daughter from us. This would save their faces irrespective of what the sheikh decides to do and would also give the young anxious wife a feeling of pride and security. He then told them that his decision is to allow the girl to return to her husband but that she should not travel to live with him in the Capital. She should have her own room in the house of her parents and her husband can come to stay with her during his weekends and vacations. The little town is joined with a highway from the Capital Khartoum and bus service that takes about two hours is inexpensive. He told them that she willenjoy her relationship with him as he comes longingly to her but he cannot beat her in her own parents' home. And since they relate to each other for comparatively briefer periods, they would less likely have communication breakdowns. My follow up of the case showed that this novel arrangement went on very nicely. The girl would frequently come in the evenings to the sheikh's compound to say her Maghrib prayers. She kisses the hand of the sheikh and proudly calls him, "My father". Space and time would not allow me; otherwise I would have given the readers many more examples of this kind.
Islamic psychotherapy is essentially a spiritual therapy:
Judging from our discussions so far, the reader should by now appreciate our argument that if the therapy of Muslim patients is to be successful, it should be spiritual in nature. Though this discussion is taking us away to a coming section on cognitive therapy, I must say here, particularly to young training counselors and psychotherapists not to avoid using the treasures of therapeutic spirituality in helping their patients. In my long experience, I have learned not to avoid discussing Islamic issues with my patients and counseled. Of course I first do it very gently until I make sure that my patient would not be offended by discussing his religious commitment. In almost 40 years of working in this field I have not come across a single Muslim patient who had not benefited from our discussion of spiritual matters. On the contrary, adopting an Islamic approach in therapy has actually helped many of my patients who were referred to me by psychiatrists working in the same hospital stating that their patients had not benefited from drugs, ECT, or other forms of secular psychotherapy. The spiritually tranquilizing feeling of God's Power and His love to the humans He Created, the fact that the pains and anxieties that the counseled is suffering from has a meaning and are a test for which he will be rewarded by Allah, that anyway all life on this earth is temporary and whatever happens to a believing Muslim will soon be over can do wonders in helping the patient to see things differently. This of course as I said is treatment by changing pathological thinking and is strictly a cognitive approach..
And finally I wish to give a word of advice to the Islamically committed psychologists. Psychotherapy is one of the most rewarding jobs that a Muslim can do to secure God's Pleasure. Remember the Hadith of Prophet Muhammad (PBUH) that we quoted earlier that he who alleviates a hardship or a calamity of a Muslim in this world, Allah Ta'ala will alleviate a hardship for him in the hereafter. Quite often, the problem of the patient concerns his bitter relationship with a parent, a spouse or a relative. It is here that the therapist can really be rewarded by Allah if he gradually changes the heart and mind of his counseled until the problem is solved. In such cases, the therapist should put aside his western training and should act like a wise loving brother, sister or parent who makes use of his local culture and religion to neutralize hatred and enmity. It is here that early Muslim scholars such Al-Ghazali, Al-Balkhi and Miskaweh would be the guides and educators, not Rogers, Wolpe or Mas low.
One case in this connection that I cannot forget is one in which the son, a professional, was so badly treated by the father and the step mother that he once tried to commit suicide as an adolescent. When I first saw him he was depressed but very angry. It took a number of sessions to help him ventilate and release his bottled emotions. Then following sessions discussed the rights of parents and children in Islam supported by Verses from the Holy Qur'an, Ahadith of the Prophet and stories of pious children. This was followed by a warm discourse about understanding his behavior and irrational thinking and that of his elderly father who was a highly successful rather arrogant professional. When the time came, I asked the father to attend our session. I listened to them and interfered only to advise with Islamic and culturally accepted wisdom and to cool down heated arguments. They gradually started to see where their real problems were since they had never before sat to discuss these issues in a cool setting. I was so happy to accept their invitation for dinner and to see them in their home happily interacting in a loving manner. So, one of the vicarious results of such therapies is to help the counseled to be a better Muslim. Such an outcome is indeed better than the treatment itself.
Islamization of behavior therapy The historical Islamic roots of Behavior therapy:
First, I would like to stress here that though these practical symptomatic approaches to therapy were developed in the West only during the fifties of the twentieth century, they were already known and practiced by our early Muslim physicians. For a more detailed exposition of this claim 1 can refer interested readers to my discussion on the contributions of early Muslim scholars in my book, Contemplation: an Islamic psychospirituai study (Badri, 2000). However, I will only give brief statements about Al-Ghazali, Al-Balkhi and Miskaweh to illustrate this contention. I think this summary is very essential in giving our young Muslim therapists confidence in themselves as descendants of these early geniuses.
Al-Ghazali and al-Balkhi say that just as the treatment of the body follows an opposite reciprocal approach with respect to its imbalance, the treatment of the imbalance of the soul or the psyche should also follow the same kind of treatment by the opposite therapy, what they call C. y-al -alL. Al-Ghazali clearly states that in physical medicine, "if the patient suffers from fever the doctor uses cold surfaces and if the cause of illness is a chill the doctor would use heat". Similarly he says in getting rid of bad habits, the opposite approach must be used. The examples he gave in his Ihya' Ulumadin include training in reducing food for an obese greedy person, training in spending money for stinginess, and humility for arrogance. In this and other examples, Al-Ghazali puts in plain words the theory of Wolpe's reciprocal inhibition as we have already delineated it.
He then gives clear details about the other important principle in behavior therapy; that of the gradual approach in treatment by applying a hierarchy of gradual exposures. He beautifully states that it may be difficult for some people to suddenly stop a disordered behavior in a short time. In this case he advises the Sheikh or "therapist" to take his time in gradually changing the person's very bad repugnant habit to one which is only bad, but less so and more acceptable than the earlier one, before he finally helps him to get rid of the latter bad habit. To illustrate this procedure that reminds us of systematic desensitization in vivo, he gives the concrete example of one whose shirt is stained with blood. Water cannot remove the stain, but he should first use urine to soften the blood stain then he uses water to wash away both the urine and the blood.
To exemplify this gradual approach in real psychotherapeutic practices, he showed how a 'patient' who suffered from 'pathological' bouts of anger and uncontrolled hostility treated himself by a gradual approach. He hired some body and paid him to curse him in front of another person while he relaxes himself by Thikr and remembrance of Allah Ta'ala. When this was repeated until he got used to it, he gradually increased the number of people day by day and week by week until he became so cool and patient that people considered him as a fine example of emotional endurance.
In a similar attempt that looks like Skinner's operant conditioning by reward and punishment, Miskaweh suggests what is now known as self reinforcement. He stated that a Muslim who feels guilty about doing something wrong should learn to punish himself by psychological, physical or spiritual ways such as paying money to the poor, deliberately instigating a hot-tempered person in order to insult him, or fasting. These Islamically oriented behavioristic interventions were in fact inspired by the Holy Qur'an and the Sunnah of our Prophet (PBUH). For example, the Holy Qur'an, in Surat Hud, Verse No. 114, States: "And establish regular prayers at the two ends of the day and at the approaches of the night: For those deeds that are good remove those that are evil.. "
And in a Hadith authenticated by Tarmathi, it is quoted that the Prophet (PBUH) said: "Fear Allah wherever you are and follow your bad deed with a good one to wipe it out"
Thus, though they used similar psychotherapeutic interventions, our early Muslim therapists, unlike modern behaviorists, have not followed a mechanistic approach since they believed in the spiritual aspect of man and they were more interested in changing human cognitions and conscious responses rather than the atomistic secular perspective that views man as simply a responding animal to environmental stimuli. Their picture of man is built on the Islamic conviction of a holistic interaction of body, mind and soul and a belief in human free will. For this reason, modern behavior therapy achieved great successes in treating neurotic symptoms that only lend themselves to a simple behavioristic stimulus-response (S-R) model such as phobias, sexually deviant behavior and mono-symptomatic disorders. However it was found to be of little help to more complex neurotic reactions such as depression which needs to be understood and managed by a more multifaceted approach which aims at changing the thoughts and cognitions of the patient about himself and his environment in a conscious manner rather than simply getting rid of specific emotional habits. It was also found that this cognitive approach of changing the conscious thought of the patient can also be very effective in changing emotional habits.
The Muslim psychologist as a behavior therapist
The Islamically oriented psychotherapist should firstly be aware that modern behavior therapy is firmly based on a secular materialistic philosophy that view man as a soulless animal whose nature is totally determined by his environment. Like a dry leaf, behaviorists believe that the environment with its rewards and punishments can shape him in any psychological mold. So, to them there are no fixed values of right or wrong or halal and wram. Each culture 'condition' its society into accepting certain values and rejecting others so that life of man on this earth is ethically relative. The feelings associated with rightness and wrongness are only "conditioned responses" learned in the way a hungry dog would salivate to the sound of a bell if it is paired with food or a rat that presses a lever if this operant brings food or terminates a painful electric shock.
Secondly, the Islamically oriented psychotherapist should realize that western behavior therapists, particularly the early ones, believe that they are scientists of behavior who aspire to control and predict normal and abnormal people's actions. For behaviorism to be a science, as we said earlier, it must limit itself to the observable aspects of human behavior. Soul, consciousness, mind, human free will, transcendence, spirituality and other mentalist and spiritual features that give man his unique characteristics are seen as either simply an illusion or are considered too shapeless to be worthy of scientific investigation. Based on this, behavior therapy opted for the reductionism of all simple and complex human behavior into stimuli that directly bring about responses.
As Muslim therapists we should reject this secular philosophy and its conception of man but not the useful techniques of behaviorism. This is so because the Islamic therapeutic practices of our early physicians made use of these techniques. Reciprocal inhibition and the gradual approach in changing behavior, as we have seen, have been applied by them within an Islamic worldview. Hence, we shouldn't throw away the baby with the bathwater. However, as Muslim therapists we must not see ourselves as surgeons of pathological behavior nor distort our conception about the nature of man by artificially forging complex and spiritual activities into an S-R paradigm.
Nevertheless, we may be justified in treating simple mono-symptomatic phobias without taking the complex thinking and religious beliefs of the patient into consideration. An example of this is a person who develops a phobia of riding a car after he has had an accident. Such a person may be tranquilized by muscular relaxation or a hypnotic trance or a drug and then instructed to imagine pleasant scenes that enhance his psychologically peaceful condition. While thus relaxed, he is asked to imagine himself in very mild scenes of being in a car. This is repeated until it causes him no anxiety. Following this, the therapist would take him gradually to more anxiety provoking scenes. The hierarchy may be something like that: to be in a stationary car, a car driven in a very low speed in an empty road, and then the speed is gradually increased and the roads made busier. When he imagines himself in a car traveling at 30 miles an hour, the therapist can in reality drive him in a car traveling at 10 miles an hour and so on until he can actuality be driven in a speeding car. This kind of systematic desensitization is very successful with such disorders.
With God's support I was able to treat many such patients. For example a female patient who had the irrational fear of closed spaces (claustrophobia) was able after a few sessions of gradually being placed in smaller and more confined rooms to be locked up for a long time in a closet. Another patient who had an incapacitating phobia of insects was after therapy able to allow a cockroach to walk on her hand. One does not need to bring Islamic beliefs or cognitive aspects into such therapies.
At times, even sexual dysfunction that is generally related to the patient's attitudes and beliefs can be treated by this simple behavioral systematic desensitization if the disorder is a straightforward case of a learned negative habit or some form of association. As a young girl, a Saudi female patient who had probably heard revolting stories about oral sex or for some other reason has associated penile penetration with something thrust in her throat. When she got married, she enjoyed foreplay with her husband but whenever he started to penetrate her vagina, she became terribly nauseated and she vomited over herself and her disgusted husband. The husband was so disturbed. He was afraid that he may lose his sexual potency.
It was clear to me on referral that her problem did not need cognitive intervention or changing her thoughts and beliefs. The husband was quite cooperative in doing exactly what I told them to do. "Approach her while clothed", I said, "and externally use your hand to bring her to orgasm". Following this step he was instructed that after his stroking made her sexually stimulated to gently try to insert his clean lubricated finger in her vagina and to take it quickly out if she said she felt nauseated. If this happened he was to repeat his foreplay until she was ready again and then to retry to insert the finger. After such few encounters he was to gradually shed off his clothes and use his penis to first rub externally avoiding sudden penetration and to proceed gradually. The wife responded very well to this treatment. This gentle gradual approach allowed her to enjoy full penetration in a few weeks. It is with such experiences that the Muslim therapist can correctly decide when to directly change a straightforward conditioned habit and when to mix up behavior therapy with cognition and spirituality. However, even in unlearning such habits the Muslim therapist should not forget to help his patient be a better Muslim.
In talking about the Muslim psychologist as strictly a behavior therapist, I concentrated my exposition to systematic desensitization and practical retraining. Behavior therapy has of course many other techniques such as aversion therapy, assertive training and modeling, however systematic desensitization continues to be the most used and the most successful. I will discuss assertive training in the following section on cognitive therapy since it often involves the changing of thinking and beliefs and not the simple S-R therapy. But I will say a few words about aversion therapy in this section.
As we said earlier, unlike systematic desensitization in which the patient wishes to unlearn a troubling emotional habit, in aversion therapy, the patient wishes to get rid of some enjoyable behavior on which he is hooked such as homosexuality, alcoholism or gambling. Aversion therapy is also used to extinguish unwanted repetitive behavior such as tics and compulsive disorders. In aversion the therapist aims at associating the unwanted behavior with a painful or offensive stimulus such as electric shocks, offensive odors or chemicals that cause ugly symptoms such as nausea. As in other behavioral treatments, the therapist can simply use a classical behavioral S-R approach or combine the treatment with cognitive therapy that aspires to change the thinking and beliefs of the patient.
As a simplified method for eliminating an unwanted repetitive response, I can give the lay reader an illustration of the case of a woman who for some reason developed the habit of pulling her hair. When she was referred to me in the Clinic for Nervous Disorders in Khartoum, she had already pulled out enough hair to look bald in the frontal side of her head. She did this unconsciously so that when she realized what she had been doing, already a few hairs had been pulled out. Electrodes were attached to her left hand and she was told to consciously try to pull out her hair with her right hand but every time she did so, she received a mild electric shock. The shock came at times as soon as she touched her hair and at other times when she actually pulled it and few times she was not shocked. This is to make the aversion variable. After very few sessions she reported that she seized to be unaware of pulling out her hair. Whenever her hand went up to her head she remembered the shock. In a few more sessions she was completely cured. In such cases, one does not need to go into a religious discourse or changing the patients thinking. It is a straightforward classical behavior modification.
An example illustrating the necessity of combining aversion with cognitive therapy is seen in treating clients who wanted to get over their homosexuality. Their sexual impulses that are aroused in the clinic by visual or imagined scenes can be electronically identified. As soon as the instruments show that the client is homosexually stimulated, he is quickly punished by a harmless but very painful electric shock of a very low current and high voltage. At the end of the session clients are encouraged to generate sexual feelings to imagined or pictured women. With repeated sessions, the client would gradually shift his interest to females and to associate homosexual feelings with the aversive stimuli. I successfully used this technique with both electrical and offensive odors, but I combined it with repeated statements about the sinfulness and spitefulness of homosexuality from the Islamic point of view and did an effort to show the client how changing his orientation can bring him the reward and forgiveness of Allah Ta'ala.
The Islamization of cognitive therapy Islamic historical roots of cognitive therapy:
Again I must repeat that it is very important to relate the cognitive therapeutic endeavors of the modern Muslim psychotherapist with the legacy of his great Muslim forefathers. He should be proud of this heritage and should see himself as a revivalist of earlier contributions and not an emulating impersonator of western therapists. He should realize that this cognitive approach to therapy that changed the face of modern psychology was definitely not a new approach to early Muslim physicians and thinkers. Scholars like Ibni Alqayyim, al-Balkhi, al-Ghazali, Miskaweh and many others have already detailed its theory and its applied therapeutic practices of changing the thinking and cognitive processes of patients in order to treat their emotional disorders. Let me give an illustration from the theoretical work of Ibni Qayyim and the treatment practices of al-Balkhi that I have summarized from one of my earlier publications (Badri, 2000).
When one reads how Ibni Qayyim discussed the cognitive roots of human behavior in his famous book titled, Al-Fawa'id he would think that he is reading a modern book on cognitive psychology. He unambiguously says that anything a person does originates first as inner thou hg t or concealed speech or internal dialogue for which he uses the right Arabic word, khwatir. The word khawatir is the plural of khatirah which stands for fast inner concealed reflections or sub-vocal thoughts which comes in a fleeting fashion. Compare this with the Beck's idea of "automatic thoughts" that we have already mentioned. Though Beck claimed to have discovered this phenomenon in the seventies of the twentieth century after the computer revolution, Ibni Qayyim had already detailed it centuries before he was born.
Ibni Alqayyim details the exact process by which these inner fleeting thoughts develop into human actions and observable behavior. He warns that a sinful or emotionally harmful khatirah, if accepted and not checked by the concerned person, can develop into a strong emotion or lust shahwah. If this is entertained or given credence it may generate so much cognitive strength that it may develop into a drive or impulse for action. If this impulsive drive or emotional motivation is not neutralized by its opposite emotion or resisting drive, it will be acted out in reality as external behavior. He further stated that if this behavior is not resisted it will be repeated so often that it will become a habit. In this respect Ibni Al-qayyim believed that emotional, physical and cognitive habits follow the same course. Using a different cognitive root, Ibni Qayyim writes that inner thoughts lead to conscious thinking. Next, thinking will be transferred or stored in the memory and the memory will transfer it into volition. This will form a strong motive which will be acted out in real life as an action. Repeating the action leads to a strong habit.
But then, Ibni Qayyim does not simply describe these cognitive processes in the neutral disinterested manner of modern western psychologists. He Islamizes his amazing exposition by relating it to improving the behavior of the Muslim thus teaching us a practical lesson in Islamization. He advises the Muslim, in the words of a cognitive psychologist, to lead a happy and righteous life by fighting the negative inner evil thoughts or wasawis before they become an impulsive emotion. This is an easy endeavor in comparison to fighting an impulse. Resisting an impulse with an opposite antagonistic motive is easier than changing the behavior after it is actually performed. However withholding an activity performed only for one or a few times is better than waiting till it becomes a habit.
He warns us that God has not given man the ability to totally eradicate fleeting thoughts and reflections or khwatir . They are as irresistible as breathing, he affirms. A wise person who has strong faith in God can accept the good khwatir and avoid the bad and potentially harmful ones. God, he states, has created the human nafs or mind in a way very similar to a rotating millstone which never stops day or night grinding at all times. Something must always be put in it to be grinded. Some people feed their minds with good thoughts; they are like those who put corn and wheat in their mills. They get nice flour. But the millstone of most people grind dirt and stones.
When the time for making bread comes (in the Hereafter) each group will know what their mills were grinding!
Abu Zaid al-Balkhi who lived as early as the ninth century is probably the first cognitive and medical psychologist who was able to clearly apply the theory of cognitive therapy in healing all sorts of anxiety disorders and obsessions. In fact he was the first to differentiate between neuroses and psychoses, to classify neurotic disorders, and to show in detail how rational and spiritual cognitive therapy can be used to treat each one of his classified disorders. Al-Balkhi classified neuroses into four emotional disorders. These are fear and anxiety, anger and aggression, sadness and depression and finally obsessions. In his masterpiece titled, Masalih al-Abdan wa'1-Anfus, (MS 3741, Ayasofya Library, Istanbul) that translates as, "The sustenance of body and soul", this great Muslim genius presented the civilized world of his time with a manuscript containing medical and psychotherapeutic information that was only discovered or developed more than ten centuries after his death.
I do not have enough space to discuss al-Balkhi's valuable contributions in detail. However, I must say a few words about his matchless clinical works in cognitive and behavior therapy and psychosomatic medicine. Al-Balkhi emphasized the role of inner thinking in causing emotional disorders to the extent of suggesting that just as a healthy person keeps some drugs and First Aid medicines nearby for unexpected physical emergencies, he should also keep healthy thoughts and feelings in his mind for unexpected emotional outbursts. As is clear from his simile, al-Balkhi's psychotherapy is mainly what we call today "rational cognitive therapy". For example, when discussing fear and anxiety, he gives a number of vivid clinical illustrations of anxiety related to expected future problems such as losing one's job or health or panic related to a phobia of thunder or death after which he says that most things that people fear are not really harmful if people use their rational logical thinking.
He quotes a very indicative simile picturing the fearful panicky neurotic as a Bedouin who travels to a cold humid country and sees fog for the first time. He thinks that this thick fog in front of him is a solid impenetrable object. But once he enters into it he discovers it is only humid air, not different from the air he was just breathing. With his cognitive rational therapy, he deduces that treated neurotics would realize that most of their fears, worries and enmities were irrational. Moreover, whenever he discusses acute emotional states, he suggests treatment by the opposite or al-ilaj bidhidh "reciprocal inhibition" as well as a gradual approach in healing to facilitate cognitive therapy.
Another very fascinating feature of al-Balkhi's cognitive therapy is the use of one unacceptable cognition or emotion to change another more incapacitating one. He gives the example of a soldier who suffers from excessive fear and anxiety from combat. He should remind himself of the heroes who courageously led their troops to win fierce battles and to be recorded in the history of their nation. By comparing his shameful emotional state with their valor, he is bound to rouse anger at himself. This anger can be further stimulated by asserting to him that this kind of panicky behavior is expected from women and children and not from an adult fighter like himself. When the anger at his unbecoming behavior reaches a certain level it would neutralize his fear. So anger, which itself can be a disordered emotion may be used against another more serious emotional pathology.
The Muslim psychologist as a cognitive therapist
It is clear from this brief historical exposition that the Muslim as a cognitive therapist is guided by a rich Islamic heritage of his past. However, in our modern times, he would find himself rather confused by the growing number of seemingly different cognitive therapeutic techniques, each of which claiming superiority over the others. This phenomenon is due to the fact that just as cognitive psychology has transformed the whole field of psychology, its applications in therapy has revolutionized western psychotherapy. Cognitive therapy has proven itself as the most successful form of treatment particularly to certain disorders such as depression in which a number of well-controlled experimental researches with long-term follow-up has confirmed its superiority over antidepressant drugs (Evans, et al., 1992; Simons, Murphy, Levine, & Wetzel, 1986).
Psychotherapy in the west is a business enterprise, so it is only natural to find well-known psychologists competing in developing 'new' techniques of cognitive therapies that are not really very different from each other in order to get their piece of cake from the unlimited funds paid by patients and their insurance companies. As we mentioned in an earlier section of this paper, all cognitive therapies are based on the simple belief shared by our early Muslim scholars that emotional disorder is caused by negative thinking patterns that distort the picture of the way the person views himself, his acquaintances and the world at large causing him or her to be anxious, depressed, angry, or suffering from some other psychological or psychosomatic disorder. Hence, all forms of cognitive therapies have one aim: to alter the client's thoughts, attitudes, beliefs and even his or her distorted mental imagery that generate his symptoms.
Most techniques of cognitive therapies combine their treatment methods with behavior therapy. Some clearly declare it such as cognitive behavior therapies (CBT) and some others use it but give it a different name. Among those who declare it, a number of them stress that their major role is that of correcting the irrational current beliefs of patients. The most famous among them are the Rational-Emotive Behavior Therapy (REBT) of Ellis and the Rational Behavior therapy (RBT) of Mauldsby. Furthermore there are techniques that emphasize on the treatment of early maladaptive childhood conceptions that the person develops about himself and others thus forming the core of his personality and continuing to influence his neurotic behavior as an adult The most famous is Schema therapy.
We cannot, of course discuss these therapies in any detail. We shall instead categorize them into three major techniques and briefly talk about them from the point of view of the Muslim therapist. We believe that Islamic cognitive therapy can be helpful to Muslim patients in three ways. First, a simple uncomplicated change in negative thought can be quite beneficial to some patients whose distorted religious beliefs are functional in causing the disorder. In his early version of Rational Emotive Therapy (RET), Ellis emphasized the changing of the faulty irrational beliefs and thought of his patients in accordance to his "ABC" cognitive theory. "A" stands for Activating experiences or events in the environment. "B" stands for the Beliefs that are formed by the faulty ways the patient views these events. And "C" stands for the Consequences or feelings and behavior that the patient engages in as a result of his negative beliefs. This should remind us of the resemblance that we mentioned earlier between this theory and the workings of the computer. The strikes on the keyboard stands for "A", the software that interprets the strikes for "B" and "C" is represented by what appears in the monitor. This is a purely cognitive approach that is not mixed up with behavioral techniques.
I found that explaining away faulty beliefs according to this "ABC" approach can at times bring about dramatic relief to clients who had lived for years harboring incapacitating guilt about their relationship with Allah Ta'ala. They had committed what they thought was unforgivable sins and have accordingly despaired from God's Love and Forgiveness. Many of them are poorly schooled in Islam as a religion and worldview and as children they had been brought up by parents who emphasized God's revenge and punishment and had ignored His Kindness, Love and Forgiveness. For years they had been worriedly expecting God's retaliation and punishment. This caused them to view all the normal problems and illnesses and pains of life as evidence for their pessimistic thoughts. They come to see me after their cognitive aberration had taken its toll, leaving them as panicky, depressed, and insomnic unhappy souls expecting a catastrophe round every corner of their miserable life.
I directly attack their pessimistic thought with evidences from the Holy Qur'an and Blessed Sunnah and prove to them that their belief of losing hope in God's forgiveness is Islamically a much greater sin that what they had committed. The Qur'an States: " And do not despair from the Mecy of Allah for it is only the disbelievers (the kafireen)who despair from God's Mercy." (Surat Yusuf Verse 87)
I read to them the stories from the Prophet's sayings such as the story of the man whose sins were forgiven after he sincerely repented though he had killed one hundred persons and the story of the Israeli prostitute who gave water to a thirsty dog in the desert and Allah pardoned all her sins and Rewarded her with Paradise. I tell them that the Hajj, the accepted Umrah and the good deeds to the poor and the orphans will neutralize whatever they had done in the past. I read to them the highly optimistic Hadith of our Prophet in which he says, "If human beings do not sin at all, then Allah Ta'ala would have created other creatures that commit sins so that he may forgive them since he is the Merciful Forgiver of sins.' (Authenticated by Ibru Amr).
Many of them hear this warm, loving and optimistic aspects of God for the first time in their lives. To many of them, it is like a healing earthquake shaking the very depths of their psyche. While in this spiritual ecstasy, a simple explanation of how their distorted beliefs have caused their psychological problems according to the "ABC" approach can bring about a sudden insight and even at times full cure in this single session.
This spiritual cognitive intervention is also very useful in helping bereaved patients and those who lost valuable property. For the person who lost a loved one, a warm discourse about the Islamic beliefs concerning death and how spiritually the process of dying is like a rebirth in which the soul is elevated to higher consciousness and that it does not lose contact with its beloved relatives who are still living is comforting to many bereaved. They should be made to appreciate that to believe that death is the end of everything concerning the deceased is a materialistic point of view. Life itself is a gift from God that He would soon take it back and good Muslims will then see their relatives who died before them and live with them in total happiness. This information is supported by selected verses from the Holy Qur'an and the Blessed sayings of the Prophet (PBUH) illustrated by stories of devoted early and modern Muslims who patiently accepted the death of relatives and friends. They are informed about the authenticated Prophetic sayings that the patience and prayers for the dead relative grants him happiness and Divine Forgiveness and that the impatience and loud expression of grief in a way that resembles open protesting against God's Qadar and destiny can cause the deceased pain in his or her grave.
The second way in which cognitive therapy can be helpful to Muslim patients is when it is coupled with behavior therapy. This combination in its limited form would reduce the role of the cognitive so that it can only serve as a minor aid to behavior modification. It often happens that a patient suffering from a mono-symptomatic disorder may need a little cognitive push to step up the behavior therapy. For instance, as I mentioned in my introduction, if the phobia is only mono¬symptomatic but is related to jinn and shaitan the therapist cannot succeed without changing the beliefs of the patient and his religious orientation. You cannot be an unbendable S-R behaviorist relaxing your patient and asking a shaitan or ghost to approach her gradually! Without a cognitive religious approach in which the patient is informed about the inability of jinn to do any real harm to her if she becomes a good practicing Muslim no abstract behavioral therapy can be of help. She must be made to believe that the only thing that shaitan can do is his concealed unconscious enticement or waswasa. Once a Muslim remembers God he is driven away.
However, as mentioned earlier, when the problem is more complex in a way that seriously affects the manner the patient views himself or others, to the extent of causing him to become socially phobic and depressed, pure behavior therapy cannot be of much value. Such patients frequently present with a mixed up assortment of a number of symptoms causing the therapist to wonder with which he can start his cognitive-behavioral intervention. I hope that the following clinical report of a patient I have treated a long time ago can illustrate what I mean.
An Arab female patient was referred to me by her psychiatrist and psychologist after all the Western healing techniques failed to bring about any change in her. She suffered from depression, social anxiety and non-assertiveness, hypochondria, anorexia and an ugly mouth tic. She needed a few sessions of psychospiritual support to begin speaking about her problems, something she had resisted to do with the psychiatrist and psychotherapist who referred her to me. Gradually she opened up speaking in detail about her predicament; her frugal husband; her superior in her office who forced her into a sexual relation; her brutal father who sided with her husband; her loneliness and non-assertiveness and lastly, but certainly not the least, her fear that God had already driven her out of His Mercy, and her panic and anxiety in expecting His divine punishment to descend upon her at any hour during her days or nights.
As a therapist, I asked myself what problem or disorder shall I start with? I have learned over the years that Muslims are unique in that in many of them, their erroneous conceptions about God and religion are almost always the core around which other disorders seem to revolve. So I followed the same cognitive spiritual approach that I have already described in order to alter her invalid beliefs about God and His Attributes. She was one of the most spiritually responsive patients that I have had in my long career. Once she began to appreciate the absolute love of Allah Ta'ala and His forgiveness to all sins, she broke down into a long cathartic tearful reunion with her Creator. She was made to see that her excessive feelings of guilt, though a clear evidence of her strong faith in God, were really built on wrong pessimistic beliefs and that her fornication was something forced on her for which she shouldn't have harbored that crippling guilt since the Holy Qur'an States:
"And do not force your maids to prostitution when they desire chastity.. .But if anyone compels them, yet after such compulsion God is oft Forgiving and most Merciful. (Surat Al-Nur, Verse 33)"
After this religiously oriented cognitive therapy, she was then ready to embark upon the second stage of spiritual cognitive behavior therapy. It was mainly a program of assertive training based on the Islamic teaching that the real fear and respect one holds for Allah (swt) should protect one from fearing other humans who are in total surrender to His might. A very useful Islamically oriented approach that Muslim therapists applying assertive training are unaware of is that they should make the patient realize that his therapy from social anxiety is a religious duty! The patient must know and feel that his soul is not his property. It belongs to God and he or she does not have the right to humiliate this soul with uncalled for degrading fear and anxiety in dealing with others. A Muslim can show humility to other Muslims but without having a phobia of dealing with them. When the patient appreciates this he would realize that treating his non-assertive social phobia is a religious duty and indeed, I found that many begin to quickly enhance their self respect after this cognition.
Our patient followed a hierarchy in which she was first asked to imagine mildly provoking scenes of social contacts that required assertive actions that gradually increased in intensity until they culminated in imagined scenes that required her to assert herself and even act aggressively with her husband, her boss at work and other imagined hostile persons. I used with her and with similar patients a technique combining a new form of systematic desensitization that I have developed in the late sixties. It was considered at the time as a forerunner to what is known today as cognitive behavior therapy. In this novel technique I combine systematic desensitization with role playing and I inject spiritual intervention whenever appropriate. I have described my this in a paper published by the Journal of Psychology, titled, "A new technique in the systematic desensitization of generalized anxiety and phobic reactions". Instead of asking the patient to silently raise her finger whenever the anxiety of imagined scenes is too much for her, as is advised by Wolpe, I ask her to close her eyes and say loudly what she visualizes from the scene I present If it causes no anxiety I ask her to go horizontally, so to tell me about similar incidents in her life that are similar to the scene in question or even to go vertically up the hierarchy. If the anxiety is too high, she simply stops talking and then I would resume relaxing her and supporting her with gratifying scenes of and spiritual encouragements and then I would ask to repeat the process until the imagination of that issue causes no more anxiety. Then I would go up to a more demanding scene. She successfully completed the hierarchy and was able while in the clinic to voice all her anger and aggressive statements to the husband and the boss. In the hospital environment, she became clearly much more outgoing and assertive. The depressive look completely disappeared and her feelings and behavior reflected this new outlook to life.
The third stage of treatment would have dealt with her anorexia, her hypochondria and her mouth tic. With the cognitive spiritual restructuring and the assertive training she did not need any treatment to her diminished appetite. It simply disappeared with disappearance of her depression and anxiety. Furthermore, when the expectation of God's punishment that could have come in the form of incurable diseases had been replaced by the optimistic hope in His Forgiveness, the obsession with impending danger has vanished and with it the hypochondriacal symptoms. The mouth tic became less frequent and less deforming to her beautiful face. Anyway I did not try to help her with it nor was she bothered by it.
She left the hospital and later informed me that she was able to refuse her husband's unfair demands and was surprised to see him behaving quite respectfully with her. This was very reinforcing to her. She said that she had no fear of facing her boss and verbally attacking him but she preferred to change her job and move to a new far away department where no body knew of her past disorder.
The third and final approach in which cognitive therapy can help Muslim patients is when the cognitive dimension becomes a philosophical one. At this spiritual transcendent level cognitive therapy would become much broader than simply a few techniques of healing anxiety and mood disorders. It develops into a form of philosophical psychotherapy; a therapy in which the patient is not only cured or greatly improved by changing his thinking but quite often a spiritual intervention in which the patient changes his whole worldview to become a highly spiritual person who finds a meaningful experience in whatever God destines for him; a submissive slave to his Master and Creator; a Muslim who worships Allah Ta'ala as though he sees Him; one who finds greater pleasure in remembering Allah than all the materialistic pleasures of this world. This is of course is the level of Ihsan described by our Prophet (PBUH). If a patient is able to spiritually elevate himself beyond his immediate complaints, he would definitely get a glimpse of this spiritual pleasure and realize some of the naYve aspects of his neurotic complaints. But of course this kind of philosophical therapy is only for the few since it would require that the therapist be in this high spiritual level and the patient to be a devoted disciple, Their spiritual relationship would then be like that of the sheikh or guru and his disciple or mureed.
A few western psychotherapists are just beginning to appreciate the importance of changing their patients' outlook to life rather than simply curing their limited disorder. They use techniques that are actually cognitive in nature but give them different names and claim their uniqueness. Of these the most well known is probably that of Logotherapy founded by Viktor Frankl. Logotherapy as an existential form of therapy is based on the belief that man has an inborn motive to see in life a meaning or a purpose to live for. This is what Frankl calls the "will to meaning". When this will to meaning is frustrated the person will develop a neurosis that he calls "existential vacuum". In treating such a disorder, the patient is helped to find a meaning and a purpose to live for and to be assisted in fulfilling this purpose. Frankl's logotherapy is rather spiritual in nature and he believes that religion offers man very rich and deep meanings to live for. Though it has different emphases than current cognitive interventions, it is nonetheless a cognitive therapy since creating a new meaning to one' life would by necessity cause him to change his thinking and his inner cognitive processes. So, a Muslim therapist using the approach of Frankl can help his patients to see an Islamic spiritual meaning in to his existence, since what purpose in our lives is more important than kowing God and being his faithful servants.
With this, I am coming to the vend of this long paper, but I do not like to shut my computer without saying a few words to the Muslim physicians.
The role of the psychological dimension in physical and psychosomatic medicine: an advice to Muslim physicians:
It is estimated that 70% of all patients who seek help from physicians for their 'physical' complaints and illnesses are in fact suffering from stress, anxiety based disorders and psychosomatic complaints. One study has even suggested that at least a third of all cardiology patients may have no real physical disorder but they suffer from panic attacks. Modern Western¬trained doctors, because of their intensive training in looking for specific bodily symptoms in which they are tested in medical schools, get used to this outlook and take it with them in their medical practice. As the famous Harvard physician, Dr. Herbert Benson, says in his best-selling book, Timeless healing (Simon and Schuster, 1996), Western trained doctors are tested in their ability to remember and diagnose specifics far more than their ability to assess overall patients. They accordingly emphasize particular symptoms over wholeness and body over mind.
For this reason, the 70% of patients whose core problem is psychological continue to receive drugs after drugs that can only help temporarily and at times only through suggestion. They may continue to see many doctors without finding one who recognizes their underlying emotional or spiritual disturbance, their depression or their sexual dysfunction as the real etiological factor in their external seemingly unrelated illness. If you add to this the 10 or 15% of those who really suffer from an anxiety or mood disorder and who know it, the total percentage of patients who need total or partial psychological or counseling services may be more than 80%.
Not only that, but also many patients who know that they are suffering from psychological problems may not get the help they really need. Because of the stigma of "insanity", many of them would not accept to see a psychiatrist, a psychologist or a counselor. And even those who do may not get the proper psychological therapy they need. Psychiatrists, as doctors who graduate from medical schools, prefer to prescribe drugs and other physical therapies to long interviews and counseling. Quite often they are burdened with too many patients exhibiting more serious mental disorders. Also their long experience with psychotic patients tends to reduce their acuity in recognizing minor psychological problems of adjustment that requires counseling or milder anxiety disorders that can be treated with psychotherapy. Many of them had not been intensively trained in the modern psychotherapeutic methods such as the use of systematic desensitization as a behavioral therapy for phobic anxieties, sexual disorders and similar problems, the use of cognitive therapy for depression and the use of aversion therapy for addictions, tics and some forms of obsessive-compulsive neuroses. Some psychiatrists who had been trained in some of these behavioral and cognitive therapies may not have the time for their application. Psychotherapy takes time to change established pathological habits. This is particularly true for those who work in private clinics. They can see more patients by briefly listening to their complaints and quickly prescribing medicines.
From what has been said, the medical services in our countries are in great need for the trained psychotherapists and counselors who can offer their tailored expertise to those who need it. General practitioners and even specialists should be informed about such psychological services and they should know when to refer some of the 80% of patients whose problems are either psychophysiological or downright anxiety and mood disordered. Since such patients can be cured or very much improved by psychotherapy and counseling, this may actually be economically cost effective in reducing the wasted hours of physicians and the expenses paid for drugs to hypothetical physical disorders that are in fact psychological in nature. Also, the training of counselors and psychotherapists would cost much less than training in medicine and would need much less time to complete.
When the number and efficiency of psychotherapists and counselors is recognized, physicians and psychiatrists would be happy to refer suitable patients to them either to be treated only by psychotherapeutic methods or to continue with their prescribed medication but for their healing to be supported by psychotherapy. On the other hand, patients who directly refer themselves to the psychotherapists and who may at times need psychiatric drugs or more serious medical interventions are to be referred to psychiatrists or physicians. Often, the patient who needs antidepressants or tranquillizers but who is afraid to go to a psychiatrist for fear of being stamped as "crazy", can benefit from the therapy of the counselor or psychotherapist who convinces him to accept referral for medical intervention. This co-operation between counselor and physician is very essential since at times purely organic disorders such as hypoglycemia and hyperthyroidism can mimic anxiety symptoms and the patient may unknowingly refer himself to the psychologist or counselor.
In modern countries that recognize the importance of psychological therapies to anxiety based and mood disorders such as the United States, it is estimated that specific phobias, which are the most common form of anxiety disorders, are more common than alcohol abuse, drug dependence, and major depression added together. These psychological disorders are mainly treated by psychotherapists and counselors. It is reported that in 1990, the United States spent 147.8 billion mental health dollars. Of this amount as much as $46.6 billion (32%) were spent on the treatment of anxiety disorders. Thus it seems that in our Muslim and Afro-Asian countries the absence of such psychological services has ironically eclipsed the dire need for them.
I believe from what I wrote in this long article that committed Muslim physicians should do their best to receive a short course or diploma in Islamic counseling. We already mentioned that a good friend can be as good as, or sometimes better than a trained counselor. So Muslim physicians should be good friends to their patients and should not limit their therapeutic approach to the physical symptoms. If they realize that the patient in front of them is a person in whose systems the physical interacts in a camouflaged manner with the psychological and the spiritual, they would be able to help him or her in these three faces of his or her problem or to refer them to those who can help. And if the Muslim physician wishes to secure God's pleasure through his practice, then he cannot avoid being a warm loving friend and counselor-physician to his or her patients.
The Holy Qur'an and Blessed Ahadith.
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