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MJP Online Early 02-06-18

BRIEF COMMUNICATION

Islam and Mental Health: A Malaysian Profile

Jean Anne Heng1, Joseph P Gone2

1Department of Psychology, University of Michigan, Ann Arbor, USA 2Department of Anthropology & Social Medicine, Harvard Medical School, Department of Anthropology, Harvard University, Massachusetts, USA

Abstract

The purpose of this research paper is to identify the intersectionality of , culture, and mental health in and to expound upon the implications for future formulations of effective evidence-based practices. This review draws upon sources including primary ones such as studies as well as secondary sources of existing literature reviews on religious and cultural tenets in Malaysia.

Keywords: Mental Health, Intersectionality, Culture, Intervention, , Malaysia

Introduction groups, this paper will focus specifically on the intersection of the religion of Islam and The discussion surrounding the the nuances of Malaysian culture. The paper interrelationship of culture and will discuss how this intersection is psychopathology has greatly advanced over manifested in the mental health landscape of the recent years, particularly with the advent Malay communities, and will culminate in of the field of implementation science, making a case for culturally-sensitive which is defined as “the scientific study of evidence-based practice in the mental health methods to promote the systematic uptake of service landscaping of Malaysia, in order to research findings and other EBPs into increase accessibility of mental health routine practice, and, hence, to improve the services to all. The nature of the paper is quality and effectiveness of health services” exploratory rather than definitive, and the [1]. The promotion of this systemic uptake initial portions aims to identify the main of research findings into routine practice tenets of the religion of Islam as well as the ought to happen within cultural contexts, aspects of certain cultural components of particularly when we take into consideration Malaysia that are imperative in forming a the scarcity of evidence regarding cultural comprehensive understanding of this minorities that often results in standard relationship. practices based on data from the majority population that have uncertain relevance for specific cultural groups [2]. While the concepts of mental health in Malaysia differ The ethnic composition of Malaysia citizens vastly between various religious and ethnic is as follows: (67.4%), Chinese MJP Online Early 02-06-18

(24.6%), Indians (7.3%) and Others (0.7%) admixture in this context. They subsequently as per a 2018 report by the Department of documented genetic structuring amongst the Statistics Malaysia, Official Portal. Among Malay populations among the Malay the Malaysian citizens, the Malays was the populations which could possibly allude to predominant ethnic group in Peninsular different historical origins [4]. As such, Malaysia which constituted 63.1 per cent. there is no present definitive conclusion as The Ibans constituted 30.3 per cent of the to the origins of Malays in Malaysia. total citizens in while Kadazan/Dusun made up 24.5 per cent in The arrival of the Chinese and Indians into . The remaining population is made up Malaysia in the nineteenth century who were of indigenous groups, also known as the brought in by British colonialists resulted in Peninsular Aborigines (1.0%). While the a diversification of religious affiliations in Malaysian Constitution declares Islam as the Malaysia [3]. A substantial portion of the official religion of the country, other Chinese population subscribe to are granted freedom to practice. and , while there exists an Amongst other legislative stipulations such extremely diverse system of beliefs amongst as allowing for the building of respective the Indians, amongst which include but are holy sites such as churches, temples, or not limited to , and . gudhwaras (Sikh sites of worships) in various states and districts, and granting Within the Malay population, cultural access to all devotees to demonstrate their differences exist from state to state but the religious affiliations through dress or overall Malay culture is overshadowed by a demeanor, the also strong influence of religion [3]. This is not recognizes other religions by declaring an isolated occurrence as it has been found national holidays on certain days of the year that the traditional belief that spiritual forces during which religious festivals are play a great role over physical and mental celebrated, the main four holidays being health is a dominant one amongst all , , Deepavali, . Some examples of this belief and Hari Raya. can be found in a study done by , Subhi, Zakaria, and The origins of the Malays of Malaysia have Mohammad Aun on cultural influences in been a widely debated topic, with differing mental health help-seeking amongst perspectives on this matter. An article by Malaysian caregivers [5]. The study found Haque and Maslan posits that the Malays of that all caregivers employed coping Malaysia were originally but began mechanisms of religious beliefs as a vital embracing Islam after the fourteenth strategy for managing the cultural issues century, before which was the main associated with mental illness due to the spiritual practice of Malays [3]. A more limited mental health resources that were recent study conducted by researchers at available in their respective communities, Universiti Sains Malaysia utilized 54,794 which was consistent with the high level of genome-wide single nucleotide religious affiliation claimed by Malaysians. polymorphism genotype data generated in four Malay sub-ethnic groups in peninsular Islam and Mental Health Malaysia (Melayu , Melayu Minang, Melayu Jawa and Melayu Bugis) to For the sake of this article, the two points of explore the history of human migration and Islamic beliefs that will be addressed in MJP Online Early 02-06-18 detail will be concerning the view on forces that results in the psyche or nafs is in humanity and mental health. control of human consciousness. As such, a study of both these forces is necessary when The Muslim belief is primarily based on the trying to develop an understanding of man. idea that science and religion work together In conclusion, ongoing purification of as an integrated whole as part of the cosmic thought and deeds bring a person closer to reality [3]. Human beings are considered a God and keeps a person mentally healthy. microcosm of the larger cosmos; The Qur’an uses the term inshirah al sadr to demonstrating the affinity between humans refer to a state of mental health or and nature and the common elements that psychological well-being as indicated in the exist between them. According to Rahman following verses: 6:125, 10:57, 16:106, [6], when God creates something, it then 20:25, 94:1. The Qur’an also uses the term falls into a pattern according to the laws of dhaiq al sadr to refer to states of nature that governs it, becoming a part of the psychological imbalance as seen in these total cosmos. The concept of free will is verses: 6:125, 11:12, 15:97, 26:13, 29:33. present in Islam; while the created elements Psychological stress (dhaiq nafsi) is also of the universe such as the sun, the moon, mentioned in the Qur’an in these verses: and the cosmos are bound to Allah’s 6:125, 9:25, 9:118, 11:12, 11:77, 15:97, instructions, human beings are granted the 16:12, 18:6, 26:3, 26:13, 27:70, 29:33, 35:8, (limited) choice of whether or not they wish 65:5. The term hayatan dhaniqah is also to follow the commands of God. The reward used to refer to a life that has psychological and punishment that comes after is based on stress (20:124). Taqwa is associated with a the choices that are made, and if they are state of well-being and psychological or consistent with or against the commands of mental imbalance is attributed to ma’siyat Allah given in the Qur’an. The seat of true [7]. knowledge in human beings comes from the metaphysical elements, referred to in the Qur’an as heart (qalb), soul (al-nafs), spirit (ruh), and intellect (al-aql). Knowledge and Article 3 in the Malaysian Federal ruh are inherent in the nature of human Constitution states that "Islam is the religion beings and are collectively known as al- of the Federation" and "Parliament may by fitrah, which directs human behavior law make provisions for regulating Islamic throughout their lives. Deviation from al- religious affairs." This allows for fitrah leads humans to go astray and leads to constitutional government intervention and suffering and pains in this world [6]. involvement in matters related to Islamic values, some examples of which will be This very idea of deviation from the provided in the next paragraph. The knowledge and teachings of Islam leading to integration of religion and culture is suffering and distress provides the basis for implicated in Article 160 of the constitution the concept of mental health in Islam. The which provides a definition of a Malay as “a suffering and pains in this world are a result person who professes the religion of Islam, of the struggle for the spiritual intelligence habitually speaks the , in man to intervene and strike a balance in conforms to Malay custom”. human personality when the physical body The effects of the synthesis of these two is in need of physical pleasure. The dynamic provisions include an increased government interplay between material and non-material presence in the regulation of Islamic MJP Online Early 02-06-18 religious affairs, and subsequently, the majority of the Malay population in enforcement of cultural practices amongst Malaysia, a large amount of administrative the Malay community. Some examples of effort and officials are involved in the government-based enforcements of Islamic administration of syariah law regardless. and cultural practices amongst the Malay community include the incorporation of The Intersection of Religion, Culture, and , or places of prayer for Muslim Mental Health students in educational institutions in order to enable the Muslim students to carry out A study done by Beverly Palmer in 2015 their obligatory daily prayers. During the used a qualitative, emic approach to assess holy month of , that is the ninth differing concepts of mental health in month of the Islamic calendar Malaysia amongst Malaysian public commemorating the first revelation of the university students. The study sought to holy book Qur’an to the Prophet determine the definition of psychological Mohammad SWT by Allah, public and well-being between various ethnic groups in private Malaysian corporations alter their an educational setting, as well as to assess schedules to account for the that the level of religious influence in the takes place amongst the Muslim workers. respective definitions of mental health Furthermore, the establishment of the concepts. The students were asked to list Tabung Haji, the Malaysian pilgrims five characteristics of mental health fund board, is a method by which a (kesihatan)/psychological well-being government-run corporation facilitates (kesejahteraan)”. For the sake of the study, savings of Malays to enable them to have both terms were used to prevent responses the funds to travel to Mecca, Saudi Arabia that would state only that mental health was for their obligatory pilgrimage. All these the absence of mental illness. The results measures could very well be the basis for the found that while all religious groups were estimation that 90% or more of the Malay about equal in identifying relational population in Malaysia is generally seen as thinking, Buddhist respondents identified practicing their basic beliefs of Islam [3]. interpersonal skills more often than did Social institutions such as schools, Christian and Islamic respondents. Islamic workplaces, and even families are greatly and Buddhist respondents identified influenced by Islamic principles that are controlling emotion more often than did integrated into the various systems. Christian respondents. Finally, Islamic respondents identified positive thinking and The justice system is yet another effective being open-minded more often than the illustration of the overlap between the other two groups. religion of Islam and Malay culture in Malaysia. There are two sets of laws The significance of the findings in relation maintained for Malaysian citizens, the to this particular article is found in the national constitution forms the basis for civil clarifications of Islamic students on the law while the second set of laws is deemed concept of open-mindedness, that is the syariah law, and is applied exclusively to “berfikiran terbuka”. Islamic students . As religion is considered a state’s defined it as being open to religious prerogative, the federal government’s teachings and they viewed those who involvement in the administration of syariah negated religious opinion as being “closed- law is limited. Nevertheless, due to the minded”, which is consistent with the MJP Online Early 02-06-18 findings of Mastor, Jin, and Cooper. This (Malay word for depression) or depresi use of the concept open-mindedness is (taken from the English word for starkly different from its use by Buddhist ‘depression’). Abdul Kadir and Bifulco and Christian students. For them, open- claimed that Malays employed cultural mindedness is to value the relativity of idioms, proverbs, or expressions to expound viewpoints [8]. The main observation here on the benefits of encountering sorrow or was that the Malay students who identified adversity, rather than addressing the actual as Muslim indicated higher attributions to issue of sadness at hand. Some of the religious principles when asked to consider examples are as follows: “Adversity makes mental health and psychological well-being, one a better person”, “The more sorrow one falling in line with the idea that religion, encounters, the more joy one can contain” culture and the concept of mental health is and “After falling, the ladder falls upon integrated in communities. you”. Such suppressions of emotional expression are said to be associated with the Furthermore, another study exploring the Islamic values that teach followers how to cultural construction of psychiatric illness in handle grief and death, whereby people are Malaysia found that in general, Malays are not expected to cry excessively and should reluctant to express their psychological express emotion in moderation [9]. problems as is and tend to somaticize their distress, in order to avoid being stigmatized It follows accordingly that the help-seeking by fellow community members [3]. The tendencies of these communities are also attribution of psychological problems to shaped by the strong religious influences in physical illness culminates in three main the Malay culture. The multicultural ways in which Malays describe their issues. approaches to healing in Malaysia reflects Firstly, the loss of “semangat” or soul the emphasis on religion by various substance makes one physically weak ethnicities. In regards to the Malay resulting in confusion. Secondly, “angin” or perspective of mental illnesses as mentioned the wind present in the stomach and in the above, a majority of help-seeking attitudes nerves and blood vessels causes tend toward the traditional or spiritual hallucinations and delusions. Finally, the approach, believing that physical tools third common belief is the possession by the containing spiritual power can be used to Jinn (Genie). It is believed that Jinn may address matters of the soul and body. As an have possessed the ancestors of the victim example of this concept, I will address a and after death the ancestors may wish to study done by Mohammad and colleagues stay in the bodies of their offspring. that interviewed caregivers in Malaysia on Psychological issues are the result of the their help-seeking tendencies based on their refusal of an individual to allow the respective ethnicities. While interviewing continued possession by the Jinn. The Muslim-Malay caregivers, they found that existence of Jinns is mentioned in the most caregivers stressed the importance of Qur’an and sometimes humans and Jinns are engaging religious coping methods when addressed together as a similar entity [3]. managing someone with schizophrenia. One The study addressed another article by Malay caregiver stated that she believed her Abdul Kadir and Bifulco, whom studied the daughter would be healed if only her spirit expression of depression among Malay would be “restored to fight the mental Muslim women and identified various terms illness”. One of the religious methods she for depressive feelings, such as murung utilized was by bringing her daughter to an MJP Online Early 02-06-18

“ustaz” (holy man) in order to attain air- help-seeking behaviors. Most (93%, or penawar (holy water). Another interviewee 56/61) of the mothers interviewed had little stated that he would recite doa (prayers) and to no idea of services offered by mental worship Allah on a daily basis for his health hospitals, and nearly all (93%, or relative’s recovery. 56/61) had a negative perception of mental illnesses. Of the few who received medical The practice of seeking help from spiritual treatment, most (75%, or 46/61) also saw a and traditional sources is also due to the bomoh (holy man) in seeking alternative limitations of alternative services in medicine. The mothers’ adherences to Malaysia. Malaysian caregivers used cultural beliefs influenced the utilization of spiritual healing to treat their relative alternative medicine from the bomoh for because of its availability as a resource in depression. Some participants also stated their community, especially when they were that alternative medicine is another form of unable to access other forms of community treatment that concurrently strengthened services [5]. This is both caused by and their religious faith and beliefs, so they results in the prevalence of traditional would not have to rely upon medical healing services amongst Malay treatment. Nevertheless, most of them communities, particularly in rural areas with ultimately accepted a combination of comparatively less development in terms of medical and spiritual treatment. In infrastructure. This was reflected in the conclusion, the use of medical services was results of the study done by Abdul Kadir and more of a last resort to solve their mental Bifulco on Muslim mothers’ experiences of health problems, upon seeking help from depression and service use in Bahru, traditional healers [10]. Southern . 61 women interviewed were selected on the basis of In general, seeking help through religious high General Health Questionnaire scores coping methods have been observed to from a large questionnaire survey of 1,002 actually alleviate distress levels as proved by mothers. The illustrative analysis provided a study done by Nur Ashikin and colleagues descriptions of depressed mood, self- that sought to determine the level of depreciation and suicidal ideation, as well as religious commitment and coping methods attitudes toward service use. The in psychiatric patients and its relationship apparentness of Islamic influence was seen with distress level. A total of 228 patients in their replies to questions regarding were included in this study. The majority of suicidal ideation. When questioned about subjects were male, Malay, Muslim, single that particular aspect of depression, most of and with psychotic disorder. Results found the other participants declared that they that the subjects had a high level of religious would avoid that kind of thinking. Many of commitment and had used more positive them replied they would try not to entertain coping methods while negative religious such negative thoughts, as a good Muslim. coping, psychiatric symptoms and diagnosis They explained that thoughts of attempting of anxiety disorder or major depression were suicide should be stopped immediately, significantly associated with high distress while wishing to die was reported in terms level [11]. A possible explanation for this of wishing God would terminate their life. would be that help-seeking behaviors that The religious and traditional connotations of fall in line with existing religious beliefs and their perspective toward this particular cultural values increased the confidence of mental illness led to the patterns in their patients in regards to the effectiveness and MJP Online Early 02-06-18 appropriateness of the treatment, which the “therapeutic alliance” is an agreement of reflected in lower distress levels. goals [13]. Research has indicated time after time that the therapeutic alliance is an Discussion important variable for psychotherapy process [14]. A direct response to this The institutionalized convergence of Islam finding can be identified in studies which and Malay customs results in a regularized have demonstrated that there are positive overlap between the official religion and the effects of religiously oriented therapies in majority , leading to the treatment of religiously observant extensive traditional and spiritual views of clients, particularly when treatment goals mental health that shape the help-seeking operate within their spiritual context [15- tendencies of Malay community members, 18]. It is therefore important that the and it is this very inextricability of religious providers of mental health services in nuances from the day-to-day life operations Malaysia first acknowledge and of the Malaysian people which is both the subsequently allow for this concept of basis of argument as well as the provision spiritual framing when engaging with one for the need for a culturally-sensitive religiously observant client or another. approach in terms of mental health services. While an overall heightened awareness of As such, while the availability of psychiatric mental health is necessary, cultural and interventions in Malaysia are increasingly spiritual elements ought to be integrated in widespread, the option of having a the management plan while constructing the religiously oriented treatment approach clinical reality of such mental illnesses and would greatly add to the help-seeking conditions so as to ensure holistic progress. tendencies of Muslim citizens encountering The studies cited have indicated high levels mental distress. Haque suggests that of spiritual and traditional influence in continuous discourses and collaboration mental health concepts and help-seeking with faith healers and religious scholars tendencies, and though religion has been would smoothen the integration process. found to play a role in delaying the seeking Due to the systemic presence of the Islam of professional help, an Islamic perspective faith in Malay communities, in order to in the understanding of mental health is penetrate resistance to the modern highly worthy of analysis while moving psychiatric interventions in the population of forward in catering to the community’s Muslim majority when or where necessary, needs. as well as to ensure the formulation of evidence-based practices that are culturally Though an increasing number of Muslim competent, the establishment of a devotees in Malaysia, particularly those in psychiatric Islamic intervention in Malaysia the urban areas, are seeking modern is worth considering. treatment in the form of cognitive- behavioral therapy (CBT) or psychotropic References medication, studies have found that Muslims who seek treatment in secular psychotherapy [1] Bauer MS, et al., An introduction to tend to have difficulty connecting to and implementation science for the non- trusting their therapists’ formulation of specialist. BMC Psychology, treatment goals [12]. This is significant as 2015.3(1). one of the three features of what is deemed MJP Online Early 02-06-18

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Corresponding Author Joseph P. Gone, PhD

1. Department of Anthropology Harvard University Tozzer Anthropology Building 21 Divinity Avenue Cambridge, MA 02138 USA

2. Department of Global Health & Social Medicine Harvard Medical School 641 Huntington Avenue Boston, MA 02115 USA

Tel: +1( (617) 496-2113

Email: [email protected]