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ORIGINAL PAPER

Islamic Integrated Cognitive Behavior Therapy: A Shari’ah- Compliant Intervention for Muslims with Depression

Zuraida Ahmad Sabki1, Che Zarrina Sa’ari2, Sharifah Basirah Syed Muhsin2, Goh Lei Kheng3, Ahmad Hatim Sulaiman1, Harold G Koenig4,5

1Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2Department of Aqidah and Islamic Thought, Academy of , University of Malaya, Kuala Lumpur, Malaysia 3Department of Psychological Medicine, University Malaya Medical Center, Kuala Lumpur, Malaysia 4Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, United States 5Department of Psychiatry, King Abdulaziz University, Jeddah, Saudi Arabia

Abstract

Objective: Depression is one of the most common mental disorders that is encountered in the health care setting. Empirically-based psychotherapy for depressed patients that explicitly incorporates client’s religious beliefs and practices has been shown to predict faster resolution and may be as efficacious as antidepressant medication. There is a demand for high-quality research to evaluate the effectiveness of modified therapies that meet the needs of depressed Muslim patients, as research has shown that most of the existing interventions are methodologically weak. A Shari’ah-compliant Islamic psychotherapy intervention is a requirement in Muslim countries that practice Sunni such as in Malaysia. Method: To address these gaps in research; we adapted a Religiously Integrated Cognitive Behavior Therapy (RICBT) that intergrates Muslim patients’ faith and practices based on the Quran and Hadith. We call this intervention Islamic Integrated Cognitive Behavior Therapy (IICBT). Results: This article describes the steps taken to identify practices, approaches and the selection of verses from the Quran and Hadith that conform to Sunni Muslim scholars. The authors provide ethical considerations and a brief description of the 10 sessions. Conclusion: Islamic Integrated Cognitive Behavioral Therapy is a manualized therapeutic approach may help to assist depressed Muslim clients to develop thoughts and behaviors to reduce depression, informed by their own Islamic beliefs, practices, and resources. Further research is recommended to demonstrate the efficacy and improve the content and application of this manual.

Keywords: , Religion, Depression, Psychotherapy, Muslim

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Introduction religious/spiritual matters gradually in therapy and this helps in initiaitng Depression is one of the most common therapeutic alliance with the therapist. The mental disorders in the general population effectiveness of such interventions depend and is frequently encountered in health care more on the patients’ religious commitment settings. A review of 25 epidemiological than on the beliefs of the therapist as long as studies suggested that 17% of Asians are the therapist is able to integrate the religious currently depressed [1]. The 1-month perspective (mindfulness, prayer, religious prevalence of major depressive disorder may concepts) in keeping with the patient’s be as high as 5.5% [2]. Due to its chronic or belief. recurring nature with significant morbidity and mortality rates, a biopsycho-social and In a meta-analysis, religiously integrated spiritual approach has been recommended CBT based on patients’ religious beliefs and by many experts. practices was shown to be as effective as the conventional CBT in the treatment of Many types of psychotherapies are known to depression and anxiety [6]. When patients be efficacious in treating depression. The incorporate healthy religious beliefs and most common evidence-based treatment is values into their thoughts, actions, and Cognitive Behavioral Therapy (CBT). CBT emotions, these clients show faster helps the patient to learn adaptive behavioral improvement of depressive symptoms [7]. strategies and develop more accurate and Despite the many studies finding a positive helpful beliefs to reduce depressive association between religiosity and mental symptoms and improve functional outcomes health, religious/spiritual issues are usually [3]. Based on the CBT model, patients’ brought up by patients not therapists [8]. depressive symptoms worsen as they are Psychiatrists and psychotherapists have been locked in a vicious cycle of maladaptive reluctant to address these issues in therapy thought patterns, behaviors and emotional citing time constraint and their ethical responses. Teaching patients how to identify obligation to maintain neutrality [9]. and modify maladaptive cognitive processes and behaviors, empowers them to become Psycho-spiritual concepts in Islam as the their own therapist, actively trying to adopt basis for IICBT adaptive behavioral and cognitive strategies that can reduce depressive symptoms and According to Malik Badri, in his book improve quality of life. In fact, behavioral “Contemplation: An Islamic Psycho- activation alone, a component of CBT, has spiritual study” [10]; early Muslim scholars been found to be effective in alleviating had already focused on internal cognitions depressive symptoms and is recommended through contemplation of God and His as a first-line treatment for mild or moderate Creations, along with self-examination and depression [4]. reflection based on the Quran and Hadith, indicating that this was a powerful force A review of spiritually-integrated towards transformation in mind and psychotherapy by Post and Wade [5]; found behavior. For Muslim patients, then, by that psychotherapists generally identify instilling these faith-centered thoughts and more with spirituality than religion as behavior, turning to God during tribulations compared to the patients. Many may assist them find meaning and purpose religious/spiritual patients prefers to initiate in adversity as a sign of God’s love for MJP Online Early 02-01-19 them. The Qur’an mentions trials and Research shows that, religiousness and tribulations repeatedly and encourages spirituality develop across the life span, believers to persevere, promisng them that related to cognitive, affective and God would grant believers spiritual psychosocial factors, and have a significant guidance. The Qur’an also describes how relationship with quality of life and mental Islamic based therapy should be approached, health [15]. Religion enhances the ability to that is with wisdom and grace: cope effectively through prayer with negative life events, illness and disability “Invite (all) to the Way of your Lord with [16], is negatively related to drugs and wisdom and beautiful preaching; and argue alcohol abuse [17], and improves quality of with them in ways that are best and most life [18]. A systematic review on religion gracious: for your Lord knows best, who and suicide risk, found that religious have strayed from His Path, and who affiliation protects against suicide attempts receive guidance” (Al-Nahl 16:125) [11]. although not necessarily against suicidal ideation [19]. It is also important to note that Islamic based psychotherapy has been found despite these positive correlations, a higher to be effective for Muslim patients suffering prevalence of depression, anxiety and from anxiety, depression, and bereavement mortality have been found among those who [7,12-14], increasing response to therapy view adversities as punishments or significantly faster. Patients are encouraged abandonment by God [20,21]. More than to identify negative thoughts and, discuss two thirds of quantitative research on issues related to their culture and illness. religion/spirituality and mental health are They are guided to the teachings of the conducted in majority Christian populations Quran and Hadith as well as to living a and very little research has been reported on lifestyle that is consistent with Islamic Islamic based therapy among Muslim teachings as revealed to the Prophet patients. As noted earlier, the results of Muhammad (pbuh). Azhar et al. encouraged those studies show improvement in well- patients to recognize religious values based being, hope and optimism, meaning and on Islamic teachings that they would adopt purpose, self-esteem, internal locus of and cultivate these in their thoughts, actions, control, depression, suicide, anxiety, and and emotions [12]. The concept of alcohol/drug use/abuse similar to Christian- repentance and forgiveness is often based CBT. However, research has also introduced to depressed patients to shown that many of the interventions overcome the effects of guilt and regret [7], conducted using religious based therapy for but needs to be done cautiously otherwise it treating depressed Muslim patients has been may trigger patient’s underlying dynamics methodologically weak. Walpole et. al. with regard to perceptions of their illness as indicated the need for high-quality research punishment from God. A proper to determine how existing therapies can be understanding of one’s spiritual relationship modified to meet the needs of Muslim with God allows the patient to rely on God clients, and stresssed the need to evaluate at all times through daily prayers and, the effectiveness of such modified therapies supplication (Duā), as these promote [22]. relaxation and enhance a sense of well-being [12-14].

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Ethical issues related to integrating Religiously Integrated CBT and Islamic religiosity into psychotherapy Integrated CBT

The Ethics Code of the American In recent years, intergration of religiously Psychological Association (APA) states that based concepts and beliefs into cognitive psychologists must consider ethical issues if behavioral therapy (CBT) is gaining they wish to integrate religious/spiritual momentum as psychiatrists and issues into their professional work [23]. The psychologists begin to incorporate these RRICC model, which stands for Respect, entities into a biopsychosocial-spiritual Responsible, Integrity, Competence and approach. The introduction of Religiously Concern, was developed to highlight the Integrated Cognitive Behavioral Therapy ethical principles relevant for all mental (RICBT) for religiously inclined clients is health professionals. Patients should first be timely as it integrates religious beliefs, educated about all treatment options, their behaviors, practices, and resources for the risks and benefits, the relevance of religion treatment of depression [26]. There are and spirituality to treatment, and asked to manuals designed for each of the five major provide informed consent before engaging religious traditions namely Christians, Jews, in religiously-integrated-based therapy [24]. Hindu, Buddhist and Islam. However, the As for the therapists, their clinical original Muslim (RICBT) version applied competence is a key ethical issue that often Shi’a concepts in its development, which is arises in providing religion-based therapy. not appropriate for Sunni patients as might Besides being well-versed in the religious be encountered in a country like Malaysia. values and practices of patients, therapists should also keep in mind the limitations of To address this gap, the authors their knowledge and clinical expertise, be (psychiatrists, experts in Islamic thought and prepared to undergo professional training aqidah, and a clinical psychologist trained and clinical supervision, and seek and expert in research conducting CBT) consultations with expert colleagues, before have revised that Shi’a Muslim RICBT practicing religion-based therapy. A Muslim manual so that it is consistent with Sunni psychiatrist must never impose religious scholars interpretation of Islam. In this values on Muslim clients, and therefore a revised Sunni version, verses from the thorough assessment of religious and Quran and Hadith have been incorporated cultural issues should first be made to with supervision from the representatives of determine the appropriateness of religious Department of Islamic Welfare of Malaysia integration. Patients who are spiritual, but (JAKIM). Permission to do so has been nonreligious, may be uncomfortable with granted by one of the original authors of this approach, and thus may not be suitable RICBT (HGK). [24]. The therapist may encourage healthy Islamic practices within and outside of The main objectives of Islamic Integrated therapy to help the patient maintain the Cognitive Behavioral Therapy (IICBT) are: practice as a way of life. However, if the patient’s cause of depression is related to his i. to apply Syari’ah compliant Islamic struggle with religious identity, the therapist approach based on the Qur’an and must be cautious as this may exacerbate Hadith in accordance to the Sunni guilt due to imagined or real previous scholars, transgressions [25]. MJP Online Early 02-01-19

ii. to apply cognitive and behavioral to the al Ghazali’s concept of restructuring based on the positive purification of the soul (Tazkiyah al principles in the Qur’an that promote ) with the ultimate objective is to mental and spiritual health, attain divine happiness (al Saadah) in this world and Hereafter. Briefly, iii. to provide a structured intervention that Tazkiyah al Nafs refers to the can also be used for research transformation process through the development in managing Muslim understanding of self (strength and patients with depression/chronic weakness), that leads to “spiritual medical illness. struggle” and through contemplative prayers and mindfulness, the patient Although IICBT adopts the framework of will use his/her faith to attain spiritual RICBT, distinctive concepts are introduced: growth, overcoming depression and achieve happiness. i. The concept of Syari’e compliant means the practice must adhere to the Session Content of IICBT declaration of Tawheed (faith to Allah and the prophet Muhammad (pbuh) as Similar to RICBT, IICBT is delivered in 10 the messenger of God) [27]. sessions over 5 to 10 weeks. Each session is 50 to 60 min in length and follows a similar ii. Through the act of mindfulness, the format. client will be introduced to contemplative prayer and mindful solat Session 1: “Building Rapport, Assessment that connects ones thought and action to and Introduction to IICBT” requires the the Mercy of God. therapist to develop therapeutic alliance with the patient and to introduce the basic format iii. The al Ghazali approach to Islamic of the program that requires the therapist to psychology advocates the application of explore any spiritual struggle in relation to the self-concept based on four his/her faith. The IIUM Religiosity Scale dimensions of man’s inner self namely (modified version) that is based on the spirit (Ruh), heart (Qalb), intellect concept of Tawheed (Islam, Iman, ) (Aql) and soul (Nafs) and outer-self [29] is used to explore patient’s spiritual and (body) [28]. Al Ghazali highlights the religious experience and to understand the impact of one’s soul on thought and patient’s faith tradition, and religious beliefs subsequent behavior and character so that this can be integrated into a client- transformation to achieve happiness. centered therapy. This seems to be the conduct of Islamic psychology which integrates both Session 2: “Behavioral Activation: Walking cognitive restructurings using Quranic by Faith”. The client’s understanding on the verses and behavioral modification treatment rationale, mood and activities self- through prayer, contemplation and monitoring is reinforced. The role of the other obligations based on Islamic therapist is to get the patient’s participation teachings and principles. and awareness in order to socialize the patient into the IICBT model. The “Pleasant iv. IICBT also briefly compares the 10 Activities” task helps to overcome sessions similar to RICBT framework depression-related inactivity and to MJP Online Early 02-01-19 encourage patient to engage in Muslim in his/her religion/God. Spiritual community. assessments questionnaire (such as RCOPE) can be used to assess the spiritual struggle Session 3: “Identifying unhelpful thoughts: the patient might be having due to his/her The battlefield of the mind” is similar to the depression/medical illness in which the level of “purification of the heart” (Takhalli patient may feel that God is punishing or concept) that focuses on steps to identify the abandoning him/her. It is crucial in session 6 thoughts that lead to negative emotions. that the therapist assess patient’s honest Contemplative prayer is introduced which is negative feelings towards God, as this may similar to meditation through the use of lead to healing and eventually spiritual verses from Quran or Hadith and it is growth. important for the therapist to guide the patient before the session ends. Session 7: “Gratitude” focuses on the Islamic based gratitude that involves being Session 4: “Challenging Unhelpful grateful to God, people, and experiences Thoughts: Bringing All Thoughts Captive” God has provided as depicted in the Quran is a continuation of session 3 which explores and the Prophet Muhammad (pbuh) is the patient’s “Thought Log” for any regarded as one with the highest level of difficulties, and discuss with the patient gratitude towards God despite been through about the trials and tribulations faced by the unimaginable sufferings. “Gratitude Prophet Muhammad (pbuh) and his Exercise – Counting Our Blessings” and companions as examples of how strong faith “Gratitude Exercise – Celebrating Our in God can move them towards purposeful Blessings” are in keeping with cognitive life. The therapist uses the patient’s faith to restructuring model that subsequently challenge dysfunctional thoughts either improves mood and also helps client to through his/her resources (al Quran and generate grateful behavior through Hadith) or through contemplative prayer and identifying any living person he would like Mindful Solah. to share his gratitude with.

Session 5: “Dealing with Loss” is for the Session 8: “Altruism and Generosity” therapist to guide patient to identify any focuses on reviewing of gratitude exercises losses (biological, psychological, social) as a which ultimately creates a form of self- result of the illness, including spiritual reflection and character transformation. losses and this is similar to the concept of Through conscious-focus, it is important to Filling-up the Heart with Positivities determine if the clients are ready to (Tahalli). Cognitive restructuring using incorporate grateful feelings and behavior verses from the Quran is used based on the into their life. Islam praises not only those patient’s “Thought Log”. The therapist may who excell in their relationship with God but quote verses in the Quran regarding the life also who put others in need above all as of the prophets and those who persevere as described in the Quran during episode of exemplary model towards strength and hope. “Hijrah”. These sessions are in keeping with the process of Tahalli or replenishing the Session 6: “Coping with Spiritual Struggles soul with positive attributes through and Negative Emotions” deals with the core thoughts and actions. experience as a result of illness and depression that may affect the patient’s faith MJP Online Early 02-01-19

Session 9: “Stress-Related and Spiritual Conclusion Growth” explore the concept of spiritual and stress related-growth based on two very Islamic Integrated Cognitive Behavioral important narations in the Quran regarding Therapy (IICBT) applies the psycho- the prophets Yusuf (as) and Ayub (as). It is spiritual concepts and theories based on the important to have correct interpretation of Quran and Hadith teachings in which the these individuals in order to engage the doctrine of oneness (Tawheed) is patient into looking for positives in life manifested in thought, emotion and while experiencing difficulties. Similarly in behavior. The faith to proclaim the Tazkiyah al Nafs, the patient is encouraged Greatness of God Almighty, Sustainer of the to self-evaluate (Muhasabah) and seek Worlds, in thought, word, and action forgiveness from God. The therapist also provides relief from distresses and worries, needs to prepare patient for the coming final therefore creating a sense of tranquility and session. security. This may assist in overcoming maladaptive cognition and behaviors such as Session 10: “Hope and Relapse hopelessness, worthlessness about the self, Prevention” explores the concept of hope future, and world, and social withdrawal and faith through the conncept of benefit- following major life events. IICBT finding (defined as the process of deriving advocates the use of cognitive processes positive growth from adversity). This is through contemplation (self-examination introduced in order to develop sense of and recollection of God and His Creations) hope, find purpose and meaning in the to bring about faith-centered thoughts and adversity as well as identify and maintain behavior. Turning to God during tribulations spiritual growths in order to achieve may lead Muslim patients to find meaning happiness especially in the Hereafter. The and purpose in adversity as a sign of God’s patient is encouraged to use the worksheets love for them; which may facilitate positive as tools, review his/her thoughts and emotional responses. IICBT adapted from behavior with referance made to the Quran the Religiously Integrated CBT originally and Hadith and the use of a journal to keep developed by Pearce et. al [26], offers a up to the daily activities and mood. Sunni Muslim version that is Syari’ah compliant and will therefore expand the Although many religously inclined Muslim potential for Islamic-based psychotherapy therapists tend to apply an Islamic approach, and research. Further research in the form of IICBT may offer a more structured randomized clinical trials is needed to intervention. Therapists need to learn how to establish an empirical basis for the efficacy integrate patients’ practices into CBT that of this Sunni Muslim based religious- complies with ethics, culture and especially psychospiritual intervention, in country like to Sunni Muslim teaching. Further research, Malaysia and other similar Sunni Muslim training and collaborative work are currently majority countries, and these are now in progress to establish the evidence-base for underway. the effectiveness of IICBT in the treatment of depression in Sunni Muslim patients.

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Corresponding Author Dr Zuraida Ahmad Sabki, Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia

Email: [email protected]