PERCEPTIONS OF MENTAL HEALTH PROBLEMS IN ISLAM: A TEXTUAL AND EXPERIENTAL ANALYSIS A Dissertation Presented by NADA ELTAIBA School of Social and Cultural Studies The University of Western Australia under the requirements for the degree of
DOCTOR OF PHILOSOPHY 2007
This thesis is presented in partial fulfillment of the requirements for the doctor of philosophy.
A Dissertation Presented by Nada Eltaiba
______School of Social & Cultural Studies University of Western Australia
ABSTRACT
PERCEPTIONS OF MENTAL HEALTH PROBLEMS IN ISLAM: A TEXTUAL AND EXPERIENTAL ANALYSIS
In this research I analyse how mental health problems are perceived in two primary Islamic texts: the Qur’an (the holy book for Muslims and the Hadith (the sayings and traditions of Prophet Muhammad). I then integrate this analysis with the perceptions of a cohort of Jordanian Muslims about their mental health problems and treatment. Two important theoretical frameworks underpin this research, namely the post-colonial theorizing of scholars such as Edward Said, Franz Fanon, and Homi Bhabha, and the Explanatory Model of Arthur Kleinman.
Research on the assessment and treatment of mental illness in Islamic and Arabic culture is limited. What literature does exist, suggests that in spite of the increase in research on cultural issues related to mental health, there is a strong need for further research to explore the nexus between culture, religion and mental health diagnosis and treatment in non-western cultures, in order to advance cultural sensitivity amongst mental health professions. This research fills this lacuna in mental health scholarship about the mental health awareness and experiences of Muslims.
All of the interviews were conducted at the Mental Health Centre in Jordan, where twenty male and female participants were selected and then interviewed using a semi-structured interview schedule. The textual analysis commenced while I was in Jordan but was completed on my return to Australia. The data were analysed using both NVivo software and manual coding. The results of this analysis are organized around the two main themes that emerged – those of ‘Causation’ and ‘Help- seeking’. Sub-themes to each of these primary themes provide a comprehensive picture of the understanding and behavior of Muslim people accessing assistance
i from a mental health clinic, and contribute to understanding of mental health issues related to Islam and to Muslims living in Jordan.
The research identifies that religion and religious belief are absolutely central to the way that this cohort of Muslim participants interpret the cause and development of their mental health problems and, further, it posits that this is due in part to the explanations of causation and coping contained in primary Muslim texts.
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TABLE OF CONTENTS
ABSTRACT...... i
TABLE OF CONTENTS...... i
ACKNOWLEDGMENTS ...... ix
Chapter One ...... 1
Introduction...... 1 Aims of the Research ...... 2 The early stage of the journey...... 2 Research Questions ...... 4 Theoretical Orientation ...... 6 Post-colonial Theory ...... 7 ‘Otherness’ ...... 9 ‘Hybridity’ ...... 10 Explanatory Model...... 12 Research Design and Methodology ...... 14 Contextual information ...... 15 Islam...... 15 Jordan ...... 17 The Jordanian Family...... 18 The National Centre of Mental Health...... 18 Ethical Considerations ...... 19 Thesis Structure...... 19 Chapter Two:...... 21
Research Methodology...... 21 Research Design...... 21 Methods...... 22 Semi-structured interviews ...... 22 The pilot study ...... 23 The participants:...... 24 Sampling description...... 24 Participants’ Profiles: Male Participants...... 27
Participants’ Profiles: Female participants ...... 29 Ethical issues...... 32 Content analysis ...... 38 Data Analysis ...... 39 Summary ...... 40 Chapter Three ...... 41
Culture and mental health: Universal challenges ...... 41 Culture...... 42 Mental health...... 45 Mental health problems...... 47 Culture and mental health ...... 49 Historical development ...... 49 Contemporary issues in mental health ...... 51 1. The problems with the term ...... 51 2. Lack of applicability of the mental health profession in non-western societies ...... 53 3. Optimism about cultural mental health...... 58 4. The struggle to find the right place for culture ...... 61 Summary ...... 63 Chapter Four ...... 65
Religion and Mental Health ...... 65 Defining religion ...... 66 The problems with conceptualizing religion...... 69 Spirituality versus religion...... 70 Mental health professionals and religion ...... 73 An early relationship...... 73 An emerging antipathy...... 76 The changing situation ...... 79 Challenges and opportunities...... 83 Summary ...... 85 Chapter Five ...... 87
Participants’ Perceptions of religion and religiosity...... 87 Perceptions of Religion...... 88 Being religious ...... 88 Religiosity and mental health...... 93 Loss of Religiosity ...... 95 Summary ...... 98 Perceptions of Mental Health Problems...... 98
The diagnosis ...... 98 Confusion ...... 103 Media as a source of information...... 103 Family, Society, and Stigma ...... 104 Forces reducing stigmatization ...... 112 Summary ...... 114 Chapter Six ...... 115
Attributing Causation of Mental Health Problems ...... 115 Introduction...... 115 Section One: In Allah’s Will: the essence of the relationship (Spiritual context)...... 118 Trial in Allah’s will...... 123 Reframing the negative: The bright side of mental health problems....126 Punishment and estrangement: When not keeping the relationship with Allah...... 128 Qadar (fate): the power of Allah ...... 131 Section Two: The Spiritual World: The Invisible power...... 135 Jinn: The invisible nation...... 135 Sorcery in Islam: The Sihr ...... 141 Jinn and perception of Sorcery among Participants...... 143 No effect: At least in my case ...... 143 Hesitantly: Yes, possibly it has an effect on my case ...... 147 Has an effect on my case...... 148 The Eye of Envy: Hassad ...... 152 Envious Eye: Perceptions of participants...... 154 Section Three: Socio-political or physical causes ...... 160 Social and political causes within participants ...... 160 Social, familial level ...... 161 Childhood experiences...... 161 Marital relationship problems ...... 165 General Stress ...... 169 Political Attribution...... 173 Physical and Hereditary Factors ...... 176 Summary ...... 178 Chapter Seven...... 179
The Help-seeking Journey...... 179 Introduction...... 179 Section One ...... 182 Keeping the relationship with God: Healing in Allah’s will ...... 183 The help-seeking journey: Basic principles...... 184
The essence of the relationship ...... 187 Taqwa: submission to Allah...... 187 Tawba: repentance, returning to Allah...... 188 Tawakul: reliance on Allah ...... 190 Keeping balance...... 190 Change: transferring the self...... 191 Saber: patience, the ability to endure...... 192 Hope ...... 193 Al hamed: contentment with Allah...... 194 Expressions of faith by participants...... 195 Faith and Taqwa...... 195 Al hamed...... 198 Istighfar: asking Allah for forgiveness ...... 199 Change...... 200 Saber ...... 200 Hope ...... 201 Summary ...... 203 Section Two...... 205
The Journey toward Healing...... 205 Part one: Practices for healing in Islam ...... 206 Salat (Praying) ...... 206 Dua’ (prayers): protection from distress...... 207 Hassana (reward for a good deed)...... 207 The Qur’an and healing power...... 208 Zikr or praise of Allah...... 209 Social role as part of religious practice...... 210 Practice of healing by participants...... 211 Dua’ Prayers...... 211 The Qur’an and Rookia ...... 211 Examples of some other religious practices...... 217 Social Role ...... 217 The effect of psychological problems on the practice of religion...... 218 Traditional Healing: the Sheikh...... 219 Views about characteristics of a good Sheikh...... 220 The Role of Sheikhs ...... 222 Calming role...... 222 Diagnostic role ...... 223 Healing role...... 224 Reasons for accessing Sheikhs ...... 227 The approaches used by Sheikhs...... 228 Family views about using traditional healing ...... 230 Part three: Professional Treatment...... 232 Views about psychiatry...... 234 The Role of the Psychiatrist ...... 236
Educating...... 237 Reassurance...... 238 Problem solving ...... 238 Religion and mental health professionals ...... 238 Psychiatry in the West...... 242 Family’s view of psychiatry...... 243 Other mental health professionals...... 245 Perception of other mental health professions ...... 247 Part Four: Seeking Social Support...... 248 Parental support...... 250 Partner Support ...... 252 Other sources of support ...... 254 Summary ...... 255 Chapter Eight ...... 257
Conclusion...... 257
Biblography ...... 271
Appendices...... 294 Appendix 1: Ethical Approval ...... 295 Appendix 2: Information Sheet (English)...... 297 Appendix 3: Information Sheet (Arabic) ...... 299 Appendix 4: Interviewing Guidelines...... 301 Background Information:...... 301 Familial relationship ...... 301 Diagnostic information: ...... 301 Coping with the problem...... 301
ACKNOWLEDGMENTS
My thanks are to Allah who blessed me with the opportunity to undertake this research. Thanks to Allah for providing me with the strength to continue the journey that this research entailed. Thanks to Allah because through this journey I have come across many wonderful things: I have learnt a lot and discovered many wonderful and supportive people.
My deep appreciation goes to my supervisor, Dr Maria Harries. Your gentle, nurturing, caring approach has encouraged me during the difficult moments throughout my research. Your expertise and support have helped me to grow independently as a researcher.
The completion of this thesis would not have been possible without the support of many people. I would like particularly to thank Professor Alean Al-Krenawi from Ben Gurion University of the Negev, Israel, for his support and guidance; Laki Jayasuriya for his input; and all my post graduate colleagues and the academic staff at The University of Western Australia, for their help and support.
I would like to acknowledge the participants in this research, whose wisdom has informed my thesis. I am humbly grateful for their kindness and honesty. They have taught me a lot. I cannot thank them enough for sharing their experiences with me.
I want to acknowledge my friends and colleagues in Australia and in Jordan, who encouraged and motivated me during the years of research. I especially thank those in the consultancy clinic whom helped me conduct the research.
ix Thanks also to Roger Bourke and Chris Walker, professional editors, for their editorial work on my thesis.
Finally, I would like to thank my family. I dedicate this work to my mother, the source of my inspiration, who encouraged and nurtured my thirst for knowledge. Thank you for believing in me. Thanks also to my father, who always encouraged me to be inquisitive, and taught me to be patient. I would also like to thank my sisters and my brothers for being so wonderful and loving. I would like to acknowledge my eldest brother, whose guidance and advice helped me to achieve my goals. Many thanks to my husband Osama for being loving, encouraging, and patient. I would also like to acknowledge my children, Luay, Luma and Khalid. I can’t express how lucky I am to have you. You have been so wonderful with your patience during the years of my research. Your encouragement, sense of humour and laughter made things far easier for me.
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CHAPTER ONE
INTRODUCTION
The current research examines how mental health problems and mental health illnesses are constructed in two key Islamic texts. It then integrates this analysis with the views of Jordanian individuals with mental health problems who accessed the National Centre of Mental Health in Amman during the period of research.
Important in the constructing of this research is the early work of Kleinman (1980), who emphasized the importance of looking at the individual’s interpretations and conceptualizations of their illness, its causes, and treatment. In his work he acknowledges the importance of cultural issues, which, he argues, people use to cope with the aetiology, symptoms, treatments, and attitudes towards disorders and difficulties. He posits that beliefs about sickness, the behaviours individuals with mental health problems exhibit, their treatment expectations, and ways in which individuals are responded to by family and practitioners are all aspects of a social reality, that has an imflunce in their understanding and treatment.
As a practitioner in the area of mental health in the Middle East and in Australia, perceptions of mental health problems have long attracted my professional attention. I have noticed how individuals of different cultures or even within the same culture seem to have different attitudes towards their mental health problems. I theorized that different perceptions and beliefs about mental health problems coloured the way people cope with problems and their approaches to treatment. Such theorizing is consistent with much contemporary theory about the importance of culture. Helman (2000) asserts that the very definition of what is normal and what is not is decided by the culture. An understanding of culture will also provide us with possible insights into the causes of mental health problems, as well as the ways problems are presented, labelled, interpreted, and treated in clinical settings.
1 Aims of the Research
From the early stages of the research journey I set out to explore the perceptions of mental health problems of participants who accessed a psychiatrist’s clinic in Jordan. I started the journey of this research with the following aims:
• To gain a better appreciation of Islamic views on mental health problems. • To examine how the cultural characterization of mental health problems and mental health are reflected in an Arabic Islamic community, particularly with regard to the manifestation and/or experience of mental health problems. • To inquire about the extent to which mental health professional programmes and services are seen to be responding to the cultural needs of people with mental health problems from Arabic Islamic communities. The early stage of the journey
At the start of my research I was working at a mental health service in Australia. Coming from a Muslim Arabic background I found myself engaged in various discussions about Islam and mental health, but was unable to answer many of the questions I was asked. I chose the research subject because I felt there was a need to help to fill the knowledge lacunae in the area of culture and mental health, especially in relation to mental health problems within Muslim communities. One of the consistent observations by researchers, scholars, and therapists about what is variously called cross-cultural mental health, transcultural psychiatry, comparative psychiatry, or cultural psychiatry is that, in spite of the increased literature on these subjects, the area that spans culture and mental health needs further research (Al- Issa 1995b; Fernando 2002). Although the influence of Arabic and Islamic culture on the understanding of mental health has been discussed in some literature (El- Islam 1982; Al-Krenawi & Graham 1997) these treatments are limited – particularly in relation to any understanding of the attitudes that Islamic people have towards mental health problems (Daneshpour 1998).
2 As a female social worker who has practised in Middle Eastern societies and in Australia, I observed that there were some difficulties in applying knowledge from professional mental health curricula (which are based largely on western philosophies and ideas) in non-western societies. I constantly struggled with the need to be committed to what I was taught at university and the realities I faced when practicing within non-western cultures. Whilst employed in Australia I met many mental health professionals who expressed the need for better understanding of mental health attitudes, beliefs, and mental health issues that related to different cultures in general and to the Islamic and Arab cultures in particular. My experience in working in Australia, the encounter with so many cultures, and the questions which I was getting from colleagues, all increased my need to want to identify these difficulties and to explore possible options to deal with them. This experience pushed me into being more reflective about my practice. However, increasingly I felt the need to go back to the mental health centre where I first practised as a social worker. I felt the need to go back to the beginning, to find an understanding, and to explore the points of view of individuals who are the recipients of help (Padgett 1998). Therefore, I chose to undertake a PhD and to conduct research in the ‘National Centre of Mental Health’ in Amman, Jordan.
Added to my interest in re-engaging with my professional roots in Jordan was the knowledge that very little research into culture and mental health issues had been undertaken in Jordan. Canda (2003) emphasized the need for more social work research in developing countries. As indicated by Al-Krenawi, Graham and Kandah (2000) mental health systems specifically these in Jordan, have neither been well understood nor researched. I anticipated that my experience working with individuals from Muslim backgrounds would put me in an excellent position to explore the cultural practices that relate to Muslim individuals with mental health problems. What was particularly significant was the opportunity I had to conduct the research with people from my own culture. Thus I have ‘insider- knowledge’ in terms of my familiarity with the culture and my speaking of the same language as participants (Kanuha 2000; Asselin 2003; Padgett 1998).
3 My plan in undertaking this research was to contribute to the understanding of the perceptions of mental health problems by Muslim individuals living in Muslim countries and, thereby, to contribute to both a local and an international understanding of these matters. I had a special interest in contributing to professional practice in mental health in Jordan. I also expected the research to contribute to the understanding of the perceptions of mental health problems of Muslims individuals with mental health problems living in western countries. So, my aim was for the research to assist mental health professionals working in divers societies such as Australia, the United States, and Canada, which have significant ethnic communities from Islamic backgrounds. (Husain 1998; Ghulam 2003). Interestingly, this goal has become even more relevant during the period in which the research has been conducted and the data analysed as there is an increase of number of migrants and refugees from Muslim and Arabic countries to western societies (Fong 2004).
In summary, whilst my academic interest in pursuing this research was motivated by a professional interest in increasing knowledge about cultural practice in mental health, on a personal level the journey was also a type of spiritual experience. Exploring and learning are part of my Muslim identity, values, and obligations. Contributing to and sharing knowledge with others in order to promote harmony and peace in the world is a spiritual obligation - my attempt to bond with the Creator.
Research Questions
My research aimed to examine the perceptions of a group of individuals who had been diagnosed with mental health problems such as depression, anxiety, and obsessive compulsive disorder. I made a very early decision not to include individuals who had been diagnosed with serious mental illness for three reasons – firstly, this would have made the research population too broad; secondly, my primary area of interest is in what are called mental health problems rather than
4 serious mental illnesses, and finally, to add a sample of people with serious mental illnesses would have added a complexity that might have added very little to the data. However, I acknowledge that this is an important area for future research.
The central question which emerged as I commenced conceptualizing the research was: How do Jordanian Muslims with mental health problems perceive their mental health problems?
It was during the first stage of the research when I was interviewing participants in Jordan and reading literature about culture, religion and mental health that I became more aware of the importance of the specific religious elements, rather than that of culture alone, in relation to mental health problems. Until this stage, although my research sample consisted of Muslim people, my focus had been on perceptions of culture rather than of religion and religious beliefs. I also began to notice that the literature that I was immersing myself in did not distinguish between religion and other aspects of culture when addressing contextual matters related to mental health problems.
As I conducted my interviews it became clear there was a need to explore perceptions of religion. Participants continually commented about religious belief throughout the interviews. A number of authors, including Larson (1998), Koenig (1998), McCullough and Larson (1998), Pargament (1997), and Schumaker (1992), have written on the importance of religion in relation to mental health. In reading this literature, it became obvious that I needed to incorporate explicit questions about religion rather than focusing more broadly on culture.
It is pertinent that when I commenced this research, a number of writers such as Nielsen, Johnson and Ellis (2001) had been writing on the need to exclude religion from mental health professions. These authors continued to counter the argument that religion has a positive and important influence on people’s attitude to mental health problems. On the other hand, some contemporary writers comment that the
5 role of religion in Muslim societies has never diminished and that religion continues to have a very strong influence in Muslim societies (Al-Issa 2000a). My interest in incorporating religion into my research increased after the events of 11th of September 2001. At this time, I was in Jordan, and Islam became a focus of international discussions.
Thus, I became aware that I needed to re-focus my research. This process of re- visiting the original research question is discussed by Denzin and Lincoln (2000), who suggest that qualitative research is generally emergent and circular; that is, as we commence the research, it develops a life of its own and new questions emerge.
The research question that was added as the research progressed was: How are mental health problems perceived in the main Islamic texts?
Theoretical Orientation
The research is underpinned by an appreciation of post-colonial theory (Said 1993; Said 2003; Fanon & Haddour 2006), which analyses the subject of power between the colonized and the colonizer, and aims to reveal the social, and political factors which contribute to the problems of dependency within those who have been colonized (Ashcroft, Griffiths & Tiffin 2006). The research also incorporates many of the elements of the Explanatory Model of Kleinman (1980). Fundamental to this is the assertion that there is a tendency by psychiatrists to impose western medical knowledge and diagnostic criteria on non-western cultures. In developing his model, Kleinman, himself a psychiatrist, aimed to assist in reducing the gap between health practitioners’ perceptions and patients’ perceptions of their psychological problems (Kleinman 1980). The fit between Kleinman’s propositions and applied research and my own research is evident.
6 Post-colonial Theory
My interest in post-colonial theory started when I was an undergraduate, and has grown throughout my career, becoming much stronger when I commenced this research. It grew with what I now understand as the dynamic interaction between tacit and explicit knowledge (Polanyi 1967). While interest in the issues related to post-colonial theory implicitly influenced this research from its inception, the decision to explicitly focus on this theory sharpened during the interviews with participants and as I analysed the associated literature.
The relevance of post-colonial theory is evident as this theory is concerned with the dialectical relationships between the western world (the ‘colonizer’) and the rest of the world (the ‘colonizeds’). Ashcroft, Griffiths and Tiffin (2006) identify that the early contributors to post-colonialism were philosophers such as Edward Said, Franz Fanon, and Homi Bhabha. Though the essence of the theory is the effect of colonization on the colonized, it also focuses on the exploration and examination of the dominant notion of European supremacy in relation to non- European cultures and societies (Said 2003; Said 1995; Treacher 2005). A number of important components of post-colonial theory are relevant. Central is critique of the idea that the West is highly sophisticated while the East is primitive. It is clear that this belief is likely to be in the mind of the ‘colonizer’ but importantly, it also is likely to be embedded within the psyche of the ‘colonized’(Fanon & Haddour 2006). Moore-Gilbert (1997) argues while Said concentrates on the colonizer, Fanon concentrates on the colonized. Fanon (1970) suggests that these intertwined relationships between the ‘colonizer’ and the ‘colonized’ have negative consequences on the personal identity as well as the social and political worlds of the colonized people. Said (1995) argues very cogently that the (mis)conceptions of the colonized people provide a historical heredity which has a continuing and detrimental effect that hinders the development of an independent identity of these colonised people (Said 1995; Fanon & Haddour 2006).
7 Moore-Gilbert (1997) argues that the West (in this instance the ‘colonizer’) imposes certain patterns of thinking on countries it has colonized in order to bring these societies into western ways and standards of thinking. The western standards are considered by the colonizers and the colonized to be based on civilized principles which the rest of the world should follow (Moore-Gilbert 1997).
This tendency to ‘dependent mimicry’ and these intertwined relationships are reflected variously at political, social and historical levels (Said 2003). Fanon (1986) argues that the discipline of psychiatry is one in which the education of the colonizer has a dominating influence. This domination, he argues, not only creates a sense of alienation and division in the colonized but also distorts the curriculum of psychiatry which becomes based solely on the ideologies and values of the colonizer. The underlining notion in all of this is the superiority of whiteness over the non-white.
Fanon and Haddour (2006) analyse a number of issues related to the alienation that is consequent to the utilization of the language of the colonizer:
A man who has a language, consequently possesses the world expressed and implied by that language (Fanon & Haddour 2006 p. 3)
Fanon suggests that the use of the language of the colonizer will challenge the restoration of the identity of the ‘colonized’ (Fanon & Haddour 2006 Ashcroft, Griffiths and Tiffin 1989). The production of literature by the colonized requires the use of the colonizer’s tools, which are imported from the West (Said 2003). Consequently, the learning of the colonized is based on colonizing values and ideology (Fanon & Haddour 2006). Fanon also argues for the need to explore important elements of culture in order to understand mental health problems in different countries. He also argues that the development of new curriculua and guidelines for cross-cultural mental health practices is urgent and that these need to
8 replace those one are so heavily dependent on values of the West (Fanon & Philcox 2004).
There are two other themes in post-colonial theory that are relevant to this research – these are the concepts of otherness and hybridity. Because of their centrality to my analysis, I summarize them in the following two sections.
‘Otherness’
Otherness is one of the basic concepts within post-colonial theory. The term suggests that the existence of the other is important in positioning the self in the world. It is also an indicator of what are the accepted standards, values, and perceptions (Ashcroft, Griffiths and Tiffin 1998) In his book, Orientalism, Said argues that the Orient has been characterized as the binary contrast of the West (Said 2003).
The colonizer portrays the subject or the others as being primitive. This is in order to create binary criteria between the colonizer and the colonized. This binarism serves to emphasize the superiority of the point of view of the colonizer (Ashcroft, Griffiths and Tiffin 1998; Yegenoglu 1998). The theory suggests that the discourse of the western language is employed to highlight ‘otherness’, and to indicate that the West is rational while the other is irrational. The West is organized, while the ‘other’ is disordered (Said 2003). Theorists suggest that the ‘‘colonized’’ tend to comply and identify with the superiority of the colonizer in this relationship (Fanon 1986). This partly serves to overturn the destruction of identity, which is based on otherness and binaries (Ashcroft, Griffiths & Tiffin 2002).
This notion of the supremacy of the colonizer is dominant to the extent that there is hardly any consideration of the points of views of the colonized. The predetermined statement of the supremacy of the colonial underlines the literature of the colonized (Ashcroft, Griffiths and Tiffin 2006; Yegenoglu 1998 p. 96). Post-
9 colonial scholars such as Ashcroft, Griffiths and Tiffin (1998) suggest that the colonial discourse influences the colonized to mimic and take on the values, traditions, principles, morals, and standards of the colonizers. As a consequence the colonized will be a ‘‘blurred copy’’ of the colonized.
‘Hybridity’
Bhabha argues that hybridity is one of the most important terms in post-colonial theory since it represents the means by which the colonized challenge the power of the colonizer and its domineering influence and culture (Bhabha 1994; Ashcroft, Griffiths & Tiffin 1998). Aschcroft suggest that hybridity focuses on the influence of integration, the mingling of identity and culture. He also proposes that hybridity occurs in post-colonial societies as a result of conscious moments of cultural suppression, such as when the colonial power invades to consolidate political and economic control or when settlers invade to dispossess indigenous people and force them to assimilate to new social patterns (Ashcroft, Griffiths & Tiffin 2006 p. 37). These authors suggest that hybridity takes many forms: linguistic, cultural, political and racial (Ashcroft, Griffiths & Tiffin 1998, p. 18).
It needs to be noted that the term hybridity is the subject of much controversy in post-colonial literature discussions. Ashcroft, Griffiths and Tiffin (1998 p. 118) note that, for some, it refers to the ‘‘analysis of colonizer/colonized relations and stresses their interdependence and the mutual construction of their subjectivities’’. Moore-Gilbert (1997) notes that Bahabha explores and underlines the ‘‘mutuality’’ and the dialogue among cultures, as well as the relationship between the colonized and the colonizer By contrast, hybridity is considered negatively by some analysts, who see it as a process in which the values of the colonized abound and they constitute substitute to a ‘‘category’’ to which all of the post-colonial unavoidably ‘‘subscribe’’ (Ashcroft, Griffiths & Tiffin. 2006, p. 137). Scholars such as Aschroft, Griffiths and Tiffin acknowledge that some might view hybridity as an
10 enriching positive element rather than a negative one. They describe the transaction between the colonized and the colonizer thus:
it is not a one way process in which oppression obliterates the oppressed or the colonizer silences the colonized in absolute terms. In practice it rather stresses the mutuality of the process’’ (Ashcroft, Griffiths & Tiffin 2006, p. 37).
Other scholars such as Nederveen Pieterse (2004) interpret hybridity to imply the incorporation of cultural symbols, and values between the colonized and the colonizing cultures, thereby producing a new familiar form developed from the integration with the colonized culture. Nederveen Pieterse (2004) views hybridity as
a central component of globalization. It is the appearance of new structure of mixing and blending of cultures (Nederveen Pieterse 2004) or: It is the process of the world becoming one (Ashcroft, Griffiths, and Tiffin 1998, p. 110).
However, in general, hybridity most commonly refers to the creation of new transcultural forms within the contact zone produced by colonization (Ashcroft, Griffiths & Tiffin 1998, p. 118).
All of these scholars argue that globalization needs to be explored within the context of the power constructs within the world and the inheritance of Western imperialism. They suggest that post-colonial theory, especially of textual and cultural practices can provide very clear models for understanding how local communities achieve agency under the pressure of global hegemony (Ashcroft, Griffiths & Tiffin 2006, p. 7).
The rapidly increasing interest in globalization reflects a changing organization of worldwide social relations in this century, one in which the nation has begun to have decreasing importance as individuals and communities gain access to globally
11 disseminated knowledge and cultures, and are affected by economic realities that bypass the boundaries of the state (Ashcroft, Griffiths and Tiffin 1998 p. 110) There is a growing awareness in the world that there are common social, environmental and health problems which are facing all societies regardless of their level of advancement and development (Said 2003). These common problems, Said (2003 p. xxi) suggests the welcome emergence of a new collective constituency that gives the often facile notion of ‘‘one world’’ a new urgency.
Explanatory Model
The research methodology is informed by the Explanatory Model of Arthur Kleinman (1980), which emphasizes the importance of looking at how individuals conceptualize their illness, the causes of their illness, and their treatment. Kleinman was one of the first researchers to direct the attention of mental health professionals to the cultural explanatory model of individuals on a model that aims to assist people to understand how they perceive their illness, as well as their reactions to medical interventions. As etiological explanations as well as casual attributions are essential in this model (Kirmayer, Young, Robbins 1994), Kleinman (1980 p. 5) defines the Explanatory Model as
the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process.
The Explanatory Model emphasizes the significance of the cultural perspective in conceptualizing and interpreting symptomatology (Kleinman 1977). These perspectives include patterns of belief about the cause of illness; norms governing choice and evaluation of treatment; socially legitimated statuses, roles and power relationships; interaction settings and institutions. According to Kleinman, both patients and healers are basic components of such systems and thus are embedded in specific configurations of cultural meanings and social relationships. The explanatory model presents the symbolic and cognitive interpretation of mental health problems applied by particular individuals in particular cultures. Kleinman
12 (1977) discusses the need to acknowledge and record the cultural strategies patients use, as well as investigate how they understand the aetiology, of their condition, its symptoms, and treatments, and their attitudes towards their mental health problems. Beliefs about sickness, the behaviours exhibited by sick persons, including their treatment expectations, and the ways in which sick persons are responded to by family and practitioners are all aspects of social realties that are explored in this model. Kleinman (1980), and Budman, Lipson and Meleis (1992), argue that it is important to note that the explanatory model of Arabic individuals with mental health problems is likely to be different from those of their counterparts in western cultures.
Kleinman (1980) explains that there is a difference between illness and disease. Disease is the biological and psychological adaptation, while illness is the experience of disease. Kleinman and Good (1985), for example, discuss the difference between the ‘‘depressive illness’’ and the ‘‘depressive disease’’, claiming that disease is universal while illness varies according to the subjective experience of individuals. In order to obtain an ‘‘illness narrative’’ Kleinman (1988) advocates the use of a ‘‘mini ethnography’’ to understand the issues related to the patients’ distress. Various questions are to be directed to the individuals to further explore their explanatory models. By following this approach clinicians then have a better chance of promoting a more positive successful encounter with individuals with mental health problems. It is recommended that the understanding of the individual’s point of view of the disorder within the whole world contribute to a better relationship with the clinicians. The understanding is what distinguishes the relationship between individuals with mental health problems and the healers. This sort of understanding is not quite promoted in the biomedical model.
Explanatory Models, as Kleinman (1980) argues, can be found in any health care system. They can provide us with better understanding in five major areas of disturbance experience: 1- Etiology of the causations; 2- timing, mode, and onset of symptomlogy; 3- pathophysiologic course; 4- history of sickness, severity, and
13 the sick role; And 5- the treatment suitable for the problem/people with emotional problems. EMs do not respond to all of these concerns. While practitioners’ models explain some or all of these inquiries, the individuals and their family respond to some of the major issues.
Prince, Okpaku and Merkel (1998) assert that Kleinman’s views have generally received a positive response. They however argue that there were some who criticised some of his ideas, such as the distinction between the new and the old psychiatry which they argue is not inaccurate, Jayasuriya (1992) notes the critics of some scholars who described the approach to be risky sometimes, with the lack of availability of rational ‘‘universal criteria’’. Fernando (2002) claims that the distinguishing between illness and disease is not always practical. Dein (2002), on the other hand, argues that the explanatory model used by individuals does not always contribute to the treatment options. He also claims that while individuals with mental health problems may have an awareness of the involvement of cultural issues in their disorder, this sort of understanding is not highly ‘‘sophisticated’’.
Research Design and Methodology
A multi-method research design is used in this research (Padgett 1998; Denzin & Lincoln 2000). Within this approach two particular methodologies are used. Semi- structured in-depth interviews are combined with an in-depth secondary analysis of key Islamic texts. The sample for the interviews was chosen randomly from a population of people who were accessing the National Centre of Mental Health in Jordan. The sample was selected by using quota sampling. A pilot study was first carried out in order to enable us to use the most appropriate sensitve language for asking questions (Janesick 1998). Two main sources of Islamic traditions were explored thoroughly. The primary purpose of the examination of these Islamic texts was to critically scrutinize how mental health problems are conceptualized and understood within the Islamic tradition.
14 In order to explore the perception of mental health problems within Islam, I chose to utilize a form of content analysis (Hsieh & Shannon 2005) for the critical examination of the texts. The two texts are the Qur’an, ‘‘the holy book for Muslims’’, and the the Hadith, books of ‘‘prophet Muhammad’s traditions and sayings’’. The Qur’an and the Prophet’s teachings are the main resources that are used to help people understand mental health problems in the Islamic world (Al- Issa 2000a, p. 44)
In the following section I will provide some context for the research by giving a brief synopsis of the Islamic religion and its history; introducing the country of Jordan and providing a brief historical and geographic overview of it; and briefly describing the National Centre of Mental Health in Jordan.
Contextual information
Islam
Religion for Muslims is a way of life. It combines social, political, and spiritual methods for living (Husain 1998). Interaction with other cultures throughout history is seen to have positively influenced and enriched Islamic identity. Islam is the last of the Abrahamic religions. There are more than 1.5 billion Muslims around the world, and Islam is the main religion in forty-eight countries (Horrie & Chippindale 2003). Muslim communities in western societies such as the USA, Canada, Europe are increasing rapidly (Al-Krenawi & Graham 2000 b).
The meaning of Islam is peace (Husain 1998). One of the basic beliefs in Islam is that it is important to acknowledge all the prophets and the holy books of Judaism and Christianity. Individuals who believe in Islam are called Muslims. In Islamic beliefs, Allah is the God and the only God and Muhammad is the last prophet sent to all human beings (Smith 1999).
15 Muhammad was born in AD 570 in Mecca. His tribe was Koreish. His father died before he was born and his mother died when he was six years old. Muhammad was raised by his grandfather and then his uncle. He is described in the historical literature as a person who was well respected among people around him due to his honesty and gentleness especially to frail and disadvantaged people. It is also interesting that he is reported to have been illiterate. He holds a great place in the faith of Muslims (Smith 1999; Husain 1998).
Muslim people believe that the Qur’an is the main text which is sent to all human beings. It is seen to be the word of Allah first revealed by the angel Gabriel to Muhammad in 610 AD. The language of the Qur’an is Arabic (Smith 1999; Husain 1998). The Qur’an scripts, which contain 114 Suras or chapters in the Arabic language, have been kept intact (without any change at all) for 1400 years (Husain 1998). It is recorded that the Qur’an was revealed to Muhammad over a period of twenty-three years (Smith 1999). The Qur’an is the basic source for helping Muslim people to learn the Muslim way of life, beliefs, and various social systems (Husain, 1998). For Muslim people, the Qur’an is considered to be a miracle (Horrie & Chippindale 2003).
The Hadith is another primary source of Islamic religion and philosophy. It contains the sayings of the Prophet, which explain how the Qur’an can be applied to Muslim lives in order that people live the best way possible. As well as incorporating the traditional sayings of the Prophet, the Hadith describes the way the Prophet Muhammad lived his life. It is another major source of information and advice on religious beliefs for all Muslim people; explaining the Prophet Muhammad’s actions and instructions, and describing the implementation of Qur’anic values and principles (Husain 1998). Muslims are instructed in the Qur’an to follow the teaching of the Prophet:
And whatever the Messenger gives you, take it, and whatever he forbids you, leave it… (Qur'an 59:7)
16 The task of collecting the Hadith was undertaken by scholars who followed a strict method of gathering material from Sahaba or the followers of Muhammad. Careful collection was needed to distinguish between the false and the authentic sayings. The most important Hadith books are Saheih Bukhari and Sahih Muslim.
Jordan
Jordan is a small country with a population of approximately 5,307,470. Some 98 per cent of Jordanians are Arabs, with a few small communities of Circassians, Armenians, and Kurds, each of which has adapted to the Arab culture. Ninety-six per cent of the population is Muslim and the remainder are Christian (Al-Krenawi, Graham & Kandah 2000). The official language of Jordan is Arabic, but English is used widely in commerce and government. About 70 per cent of Jordan's population is urban; less than 6 per cent of the rural population is nomadic or semi- nomadic. Jordan shares its borders with the West Bank, Israel, Saudi Arabia, Syria, and Iraq. Jordan is considered to be a peaceful and stable country in the middle of a stormy, problematic region, and as a consequence of this it has become a shelter for a large number of refugees from neighbouring countries. Contemporary writers suggest that this movement of people has created a demographic crisis in Jordan. For example, Jordan has within its borders about 1.7 million persons registered as Palestinian refugees and, as well as this, many other displaced persons reside in Jordan as citizens (Nation 06.12.06).
Several refugee waves contributed to the current social and demographic changes in Jordan. Jordanians tend to refer to Palestinians as persons who fled or were driven from Palestine during the Arab-Israeli War of 1948 and the 1967 War (Guide 06.11.06). The latest wave of refugees was from the Gulf area after the Gulf crisis in 1990 when a large number of people who had been working out of the country returned to Jordan. As well as this, there has been a gradual demographic change from rural and nomadic to urban living (Al-Krenawi, Graham and Kandah 2000).
17 The Jordanian Family
Jordanian families, like other Arab families, tend to be collectivist and patriarchal in nature. The predominant family structure places the family ahead of individuals (Al-Krenawi, Graham & Kandah 2000) and the male is considered the first authority and the head of the house. Obedience, respect and conformity to parents are learned from an early age. In Jordan, through the influence of modernization, and urbanization the traditional family structure is being challenged to transform into a more democratic model (Barakat 2006)). Exposure to the media, industrial capitalism (Al-Krenawi, Graham & Kandah 2000), democratization, the liberalization of women, and paid employment for women are also challenging the structure of the Jordanian family (Lowrance 1998). Despite these changes, as with the rest of the Arabic world, Jordan is a traditional society and continues to hold a strong family orientation. Family members are expected to take care of each other during crisis despite the fact that there is a gradual change from the extended family structure to the nuclear family (Barakat 1993).
The National Centre of Mental Health
The health system in Jordan is mainly provided by either the government or the private sector. However, international organizations such as the United Nations Relief and Works Agency (UNRWA), a few non-government organizations (NGOs), and other charitable associations also contribute to the health system.
The National Centre of Mental Health (NCMH) in Jordan is in Al-Fuhais village in Amman, and it was officially opened in 1987. The centre provides psychiatric treatment counselling and occupational therapy for people with mental health problems, as well as education and training for mental health professionals. There are thirty-one mental health government clinics through Jordan, and more than twenty-two private clinics. There is no fee for services provided by government clinics, for, that is, patients who access the services of or through the hospital.
18 There is a small fee for individuals who access the outpatients’ clinics that are connected to the NCMH. The majority of people accessing the Centre, and the outpatients’ clinics are people who suffer from psychotic and chronic illnesses, while the number of people with mental health problems who access the government clinics are fewer. At the time I was conducting my research there were fortyregistered psychiatrists, six psychologists, two social workers, and twenty- four occupational therapists working at the Centre and providing services to other clinics.
Ethical Considerations
Ethical issues needed very careful consideration during this research, because of the sensitivity of the subject of mental health problems in a conservative, traditional society such as Jordan. The Human Research Ethics Committee of the University of Western Australia approved the research component and methods, given suitable sensitivity towards the relevant aspects of Jordanian culture. These considerations were applied to the information sheet, the consent, and the tape recordings (see Appendices 1, 2, and 3).
As a researcher who has experience and knowledge of the Jordanian culture, I was very sensitive to the cultural elements and to the ethical considerations of the research.
Thesis Structure
The thesis is divided into ten chapters. In this first chapter I have introduced the research topic and discussed how it grew and developed. I have also introduced the research questions, aims, goals, and methodology, which are discussed in more detail in the next chapter. In chapter two, I clarify terminology, definitions and the
19 process of the research. I also discuss some of my reflections about interviewing the participants.
In chapter three, I define culture, and I provide an overview of the new transcultural psychiatry and the old transcultural psychiatry. In this chapter I detail the challenges facing the mental health profession in a globalised world. Chapter four is a chapter that explores religion and mental health. In this chapter I outline the historical and emerging literature about religion and mental health. I reflect on important concepts related to religion and spirituality.
In the second part of the thesis, chapters five. six, and seven, I present the analysis of the data. In chapter five, I analyse the perceptions of mental health problems, as well as of religion and religiosity, as these emerged from the discussions with participants. In chapter six, I analyse the data about the perceptions of the causation of mental health problems. Chapter seven focuses on the help-seeking process. In the last chapter I summarize the research and conclude with major findings and an exploration of some of the implications of the research.
20
CHAPTER TWO:
RESEARCH METHODOLOGY
This chapter will describe the research design and the research methodology employed. It will also describe how the research questions emerged, and were refined as the research progressed, The primary aims of this research were to understand and investigate perceptions of mental health problems in the Islamic religion, and also exploring perceptions of mental health problems among a cohort of Jordanian Muslims living in Jordan who are affected with a mental health problem.
Research Design
The research is partly, but not entirely, qualitative (Padgett 1998). It is exploratory, descriptive, and uses two primary data gathering methods: semi-structured interviews, and text analysis (Denzin & Lincoln 2003; Creswell & Clark 2007). These methods suit research which is largely exploratory and which deals with complex issues of cultural significance that are difficult to explore using strictly structured data-collection methods (Thyer 2001; Rubin & Rubin 2005).
Qualitative analysis entails recurrent expansion, progression, and circularity in research development; as it is different from conventional scientific methods which are more systemic and predetermined (Denzin & Lincoln 2000; Padgett 1998). Using the language of Padgett:
Qualitative researchers find themselves going back and forth between the stages of problem formulation, data collection, data analysis, and write-up. This processes is rarely linear, but instead zigs and zags depending where the data lead (Padgett 1998, p. 30).
21 Research based on this notion honours the circulity of the research questions which continually emerge from the data. Punch (1998) asserts that the emergence of new questions in many cases requires the need for various methods in order to respond to these questions.
As indicated in the previous chapter, the central question is: ‘‘How do Jordanian Muslims with mental health problems perceive their mental health problems?’’. As the research progressed the need to investigate the significance of religion became more obvious as it emerged in the early use of data. In my encounters with participants they frequently mentioned religious issues, with many believing that religion played a part in reducing their mental health distress (Al-Krenawi & Graham 1999; Al-Issa 2000).
Al-Krenawi (1999) asserts that Muslims are considered to be highly religious in terms of the ways they attribute mental health problems and seek to deal with distress (Al-Krenawi,1999). I noticed that there were a variety of ways that participants presented when discussing religion and its relation to mental health problems. Due to this variety of interpretations based on religion the research question developed to include: ‘‘What is the perception of mental health problems in the main Islamic texts?’’.
Methods Semi-structured interviews
In order to explore perceptions of Jordanian individuals with mental health problems, I chose to conduct in-depth, semi-structured interviews, using interviewing guidelines as they are described by Punch (1998) and Minichiello (1990). Grbich (1999) argues that the semi-structured interview is the most suitable, practical approach for the purpose of this sort of research, as it allows flexibility in discussions when interacting with participants. Barribal and While
22 (1994) and Fontana & Frey (1998) urge the use of the semi-structured interview as it fosters depth in the data obtained. Fontana and Frey (1998) also assert that these type of interviews provide the chance to clarify some of the issues discussed. Semi- structured interviews follow a flexible structure and agenda, where general topics are discussed, and participants are allowed to expand on the conversation and discuss their opinions. The interview guidelines addressed participants’ backgrounds and deographic information, their familial relationships and diagnostic information, and their methods of coping with their mental health problems. The guidelines were to provide a general and flexable direction to the process of the interviews (see Appendix 4).
The sample consisted of people who had been diagnosed (using the standard DSMIV, Diagnostic and Statistical Manual of Mental Disorders, classification tool) by psychiatrists as suffering from depression, anxiety, panic attacks, or obsessional disorders, and who had agreed to be interviewed. Individuals who fitted the criteria were identified by their volunteering their diagnosis and/or the notification of treating psychiatrists. They were selected by quota sampling. All individuals were outpatients at the consultancy outpatient clinic of the National Centre of Mental Health in Amman. The length of the encounter with their mental health problems varied, from a few weeks to three years.
The pilot study
A pilot study of four interviews was conducted. The purpose of the pilot study was to explore the extent to which individuals with mental health problems accepted, understood, and could respond to the questions on the interview schedule (Janesick 1998; Padgett 1998). Once the pilot interviews had been completed and the schedule reviewed accordingly, the research interviews were conducted.
The time and place of the interviews were organised in order to accommodate, whenever possible, the wishes of each individual involved in the study.
23 In the pilot study there were four participants: two male and two female. One of the male participants was Jordanian and one Palestinian. One female originally from Syria was married to a Jordanian and lived in Jordan. The other female was from a Palestinian background. Table 1 provides a pofile of pilot study participants
Table 1 – Participants in Pilot Study
Gender Age Diagnosis Employment Marital Origin statues
Obsessive M 30 compulsive Student Single Jordan disorder
M 55 Anxiety Tailor Married Palestine
F 22 Depression Unemployed Single Palestine
F 47 Depression Teacher Married Jordan
The most immediate emergent theme from the pilot study was the importance participants placed on religion as an explanatory component in their mental health problems.
The pilot interviews demonstrated that the schedule was appropriately structured and assisted me to broaden the range of questions to enable the exploration of religious beliefs.
The participants: Sampling description
The sample for the research interview consisted of ten males and ten females: all Muslims of Jordanian backgrounds, who had been diagnosed with mental health problems, and who had accessed the services of the outpatient clinics of the
24 National Centre of Mental Health in Amman. Table 2 provides a profile of the ten male participants.
Table 2 – Male Participants’ Profiles
Age Marital Country of Education Participant Diagnosis Employment range statues origin Level BA in Palestinian Mahmood 21-30 OCD Married Officer Political 90 Studies
Palestinian Uni Ali 21-30 Depression Single High school 67 student
Palestinian Alwan 21-30 OCD Single Barber High school 48
Palestinian Elementary Hussain 41-50 Panic attacks Single Baker 48 school
Burhan 31-40 Depression Married Jordanian Builder High school
Anxiety and Palestinian BA in Jameel 41-50 Married Engineer Depression 90 Engineering
Muhssen 21-30 Depression Single Jordanian Taxi driver High school
Palestinian Uni Fouad 21-30 Depression Single High school 67 student
Palestinian MA in Firas 21-30 OCD Single Unemployed 67 Engineering
Palestinian Sami 41-50 Panic attacks Married Officer College 67
25
Table 3 gives the profiles of the female participants.
Table 3 – Female Participants’ Profiles
Marital Country of Education Participants Age Diagnosis Employment statues origin level
Palestinian College Amal 21-30 Anxiety Single Unemployed 67 Social studies
Panic Palestinian Baheera 41-50 Married Housewife High school attacks 90
Palestinian Hanan 21-30 Anxiety Married Housewife High school 67
Palestinian Maryam 21-30 OCD Married Housewife High school 67
Anxiety Palestinian Degree in Nida 31-40 Widow Engineer Depression 90 engineering
Palestinian BA Nour 31-40 Depression Divorced Unemployed 67 in archaeology Panic Palestinian College Rania 21-30 attacks and Married Housewife 90 certificate Depression Palestinian University Sarah 21-30 Depression Divorced High school 67 Student
Palestinian Elementary Shakira 41-50 Depression Widow Housewife 48 school Sleep Elementary Suad 31-40 disorder, Married Jordanian Housewife school Depression
The mean age for male participants was 35.2, with ages ranging from 24 to 45. The mean age for the female participants was 33.9 years. The age range for these women was 21 to 50 years.
The occupation of the women was predominantly house duties. There was no difference in education level between male and female participants. Two of the
26 female participants were widows, one was divorced, and one single. Four of the male participants were married and six were single.
Participants’ Profiles: Male Participants
The following descriptive profiles provide a picture of the twenty interviewees at the time they were interviewed. Pseudonyms are used in all cases.
• Mahmoud was thirty years old, and he had been diagnosed with obsessive compulsive disorder. He was married and had two children, and had a BA in Political Science and worked as a training manager for a private company. He was from a Palestinian background, his family arriving as refugees in Jordan in 1967. The family lived in Kuwait and returned to Jordan in the 1990 after the Gulf crisis. He had many relatives who lived in the West Bank and maintained contact with them. Mahmoud wore a beard (which indicates religiosity within some Muslim communities). He also tended to incorporate religious expressions in his conversations. • Ali was twenty-four years old, and had been diagnosed with depression a year ago. Ali was unmarried. He was studying engineering at one of the Jordanian universities. He had been facing some difficulties completing his university studies, in spite of being a distinguished student in high school. He lived with his parents and his two brothers. He was from a Palestinian background, his family arriving in Jordan as refugees in 1967. He came to the clinic accompanied by his friend. Both looked religious as they were wearing beards. The friend left the clinic as Ali stayed for his interview with me. • Alwan was twenty-eight years old, and he had just been diagnosed with obsessive compulsive disorder. This was his second visit to the clinic. He was single, and lived with his father, three brothers and five sisters. His mother had died a couple of years earlier. He had been working as a barber for twelve years. Alwan was from a Palestinian background, his family coming to Jordan as refugees in 1948. • Hussain was forty-one years old, and he had just been diagnosed with panic attacks. He was single, and lived in an independent home away from his parents.
27 His brothers and sisters were all married and lived independently. Hussain owned a bakery. He had a low level of education. His parents came to Jordan as refugees in 1967. He still had extended family living in the West Bank. He came to the clinic with one of his friends who used the medical services in the clinic, and had encouraged him to come to get treatment for his psychological problems. • Burhan was thirty-eight years old, and he had been diagnosed with depression and anxiety several months earlier. He was married with five children. His parents had died before he completed high school. He had two sisters and two brothers. His older brother had died two years earlier. All his brothers and sisters lived in Jordan. He worked as a labourer for a construction company, and indicated that he was on a very low income. He had completed high school. Burhan was from a Jordanian background. He had high blood pressure in addition to his psychological problems. • Jameel was forty-four years old, and he was diagnosed with anxiety and depression a few weeks earlier. He was married with three children. His father was killed in an accident with an Israeli army car when he was nine years old. He had spent most of his childhood in an orphanage as his mother could not afford to support him, his brother, and his two sisters. He had a degree in engineering, and owned a company, and was well off financially. He was from a Palestinian background, his family coming to Jordan in 1967. Most of his brothers and sisters lived in the Gulf countries, the USA, or in Europe. He had lived in Kuwait and came back to live in Jordan after the Gulf crisis in the 1990s. Beside his psychological problems, he also had diabetes and blood pressure problems. • Muhseen was thirty-four years old, and he had been diagnosed with anxiety and depression a few months earlier. He was single, and lived with his mother. He had six brothers and five sisters. One of his brothers had been diagnosed with schizophrenia. Most of them lived in Jordan. He was a high school graduate, and worked as a taxi driver. He came to the clinic accompanied by his older brother, who waited for him in the reception area while he was in the interviews. He was from a Bedouin Jordanian background.
28 • Fouad was thirty years old, and he had been diagnosed with obsessive compulsive disorder a few years earlier. He was single and lived in an area about half-an-hour’s drive away from the clinic. He lived with his mother. His father had died many years ago. He had two brothers and five sisters. He was the youngest. Fouad was studying computing at university and had been trying to finish his degree for ten years. He was from a Palestinian background, his family coming to Jordan as refugees in 1967. Fouad had writing as a hobby, and had published some of his writings on social issues in some local papers. • Firas was thirty years old, and he had been diagnosed with obsessive compulsive disorder some years earlier while he was studying in Russia and the USA. He had started accessing the clinic some months before. Firas was single and lived with his parents, brother and sister. His other sister was married and lived in the USA. He had a degree in engineering and was working temporarily for a private company. He had obtained his qualifications in Russia and the USA. He was from a Palestinian background, his parents coming to Jordan as refugees in 1967. • Sami was forty-five years old, and had been diagnosed with panic attacks several months earlier. He was taking medication which had stabilised his psychological problems. He was married to a teacher. They had four children. He had a high school qualification and worked as an officer for a private company. He was from a Palestinian background and his family had been refugees in 1967. Sami had extended family in the West Bank and maintained contact with them.
Participants’ Profiles: Female participants • Amal was twenty-one years old, and she had been diagnosed with depression. She was single and lived with her parents and two sisters and three brothers in a house in one of the Palestinian camps in Jordan for refugees. Her family was from a refugee background and came to Jordan in 1967. She had a diploma in special education, and had started working several days ago in an organisation that specialised in special education. She was wearing modern clothing and hijab (the head cover worn by some Muslim women).
29 • Baheera was fifty years old, and she had been diagnosed with panic attacks. She was happily married (as she expressed it) with three daughters and four sons aged between 30 and 13. Most of her children were married and lived independently. She was a housewife. Baheera was from a refugee background, her family coming to Jordan as refugees in 1967. She was married and had lived most of her life in Kuwait. Baheera came with her family to live in Jordan in 1990 after the Gulf crisis. She was well off financially. She was wearing a jilbab (the long dress worn by some Muslim women) and hijab (a head cover). She came to the clinic with her husband, who waited for her in the reception area while I was interviewing her. • Hanan was twenty-nine years old, and she had been diagnosed with depression. She was married with three young children. She was a housewife. Hanan had completed high school and then two years in Qur’anic studies. She lived in Saudi Arabia, as her husband worked there. She was visiting her family during the summer holiday when she visited the clinic. She had four brothers and three sisters, most of whom lived in Jordan and the Gulf area. She was from a Palestinian background, her family coming to Jordan as refugees in 1948. She was accompanied by her sister, who had been a diagnosed with schizophrenia and accessed the services of the clinic regularly. Hanan was wearing a khimar (a dress worn by some Muslim women which covers the face). • Maryam was twenty-seven years old, and she had been diagnosed with obsessive compulsive disorder. She had been accessing the clinic for a year. She was married with two children. She was a housewife, and had studied until Year 9. Maryam’s husband was on a low income. She was from a Palestinian background, her family coming to Jordan as refugees in 1948 and then living in Iraq. She came with her husband and in-laws to live in Jordan after the Gulf crisis in 1990. Her mother, brothers, and sisters still lived in Iraq. Maryam was wearing a khimar. She indicated that she had only started to wear it a couple of weeks before. Prior to that she said she used to wear a jilbab (the long Muslim dress) and she used to cover her hair.
30 • Nida was forty-three years old, and she had been diagnosed with depression. She had been accessing the clinic recently, and had also accessed the clinic several years earlier for depression. She had a degree in engineering and worked as an engineer. She was a widow, having lost her husband three years ago. She had two children and had returned to live with her mother, brother and sister. She had other sisters who were married and lived independently. She was from a Palestinian background, her family coming to Jordan as refugees in 1948. Nida had lived and studied in Iraq before returning to Jordan in 1990 after the Gulf crisis. She had some difficulties with her in-laws who had taken her to court in a dispute over property owned by her husband. Nida was wearing modern clothes and a hijab. • Nour was thirty-eight years old, and she had been diagnosed with depression. She had been diagnosed for two years. She had been divorced for a year, and lived with her mother and brother. Her sisters were married and lived independently in the USA. She had a BA in Archaeology and had previously worked as a hostess. Nour was unemployed. Her family was from a Palestinian background and came to Jordan as refugees in 1967. Nour was wearing modern clothes and did not cover her hair. She approached me asking if I would interview her as part of the research. • Rania was twenty-nine years old, and she had been diagnosed with depression. She had been diagnosed for a couple of years. She had been married for three years and had two children. She had two other older daughters from a previous marriage, who lived with their father and his family. She had completed high school. Her family was from a Palestinian background, coming to Jordan as refugees in 1967. Rania had lived in Kuwait with her first husband and came back to Jordan after the first Gulf War, before the couple divorced. She was wearing modern clothing and did not cover her hair. • Salma was twenty-eight years old, and she had been diagnosed with depression. She had been accessing the clinic for several months. Salma was in the process of getting a divorce from her husband, who was also her cousin. Salma had returned to live with her parents and her brother and sister after separating from her
31 husband. She had a young child, who was in the care of Salma’s mother. Salma was a university student. She was from a Palestinian background, her family coming to Jordan as refugees in 1967. Her mother was from a European background and had met Salma’s father while he was studying medicine. They married and she returned with him to live in Jordan. Salma was wearing a head cover with modern-style clothing. • Shakeera was forty-three years old, and she had been diagnosed with depression. She had been accessing the clinic for couple of months. She was a widow, having lost her husband, whom she described as caring, a year earlier. She had four sons and a daughter. One of her children was intellectually impaired. Anther one had been diagnosed with schizophrenia. Shakeera was from a Palestinian background, her family coming to Jordan in 1948. She was wearing a jilbab (long dress) and a hijab (a head cover). She came to the clinic accompanied by her sister and her brother-in-law, who waited for her in the reception area while I was interviewing her. • Suad was thirty-one years old, and she had been diagnosed with sleeping disorders. This was her second visit to the clinic. She was married and had two boys and two girls. Her husband was abusive towards her, as she described it. She had studied up to Year 10. She was a housewife, and was from a Jordanian Bedouin background. Suad and her sister and brother were raised by her mother, who was separated from Suad’s father. Suad lived close to her family and in- laws. She was wearing a jilbab (long dress) and hijab ( head cover).
In summary, the cohort of twenty interviewees was balanced for gender and included a diversity of demographic features such as age, education and employment.
Ethical issues
As a mental health practitioner and a researcher, I was aware of the ethical issues associated with researching individuals with mental health problems. Lee’s warning is that when researching such a sensitive area the researcher needs to pay
32 particular attention to the ethics of the research (Lee 1993). Many scholars including Janesick (1998) Padgett (1998), and Lee (1993) challenge researchers to be sensitive to this matter and I followed their guidance with rigour. The following are some of the processes which I undertook to ensure confidentiality.
• Clients have a right to confidentiality. I was especially aware of the importance of confidentiality when dealing with individuals from Arab and Muslim backgrounds for whom emotional problems are seen to be stigmatizing. For them, accessing a mental health clinic is probably often considered an activity of last resort (Al-Krenawi et al. 2004). • I was very also aware of the importance of explaining my role as a researcher, to pre-empt any possible misunderstanding or mixing of the role of the researcher with that of a clinician. • In accordance with the requirements of the Human Research Ethics committee at The University of Western Australia (see Appendix 1). I stressed to the interviewees at my first meeting that they had the right withdraw consent at any time during the interview. Each individual was provided with an information sheet, translated into Arabic, which had been checked by an Arabic Professor who is a specialist in English language, to ensure the clarity of the translation. • Signing a consent form is not a familiar procedure for Arabic people accessing a medical clinic. As some of the individuals were new to the mental health system, I thought that they would feel uncomfortable signing a form and this would not be helpful in creating a trustful atmosphere. After consulting mental health professionals, all of whom advised against offering a consent form, I decided to start each taped interview with the following phrase: ‘‘I am doing this interview on the understanding that you are happy to be interviewed by me and understand the purpose of the interview.’’ The understanding was that in going ahead with the interview the participants were giving their approval. The Human Research Ethics Committee approved this format.
33 • The development of trust in the interviews was a matter of grave importance to me and one that again has been addressed by a number of scholars (Barriball & While 1994; Fontana & Frey 1998; Padgett 1998; Lee 1993).
In the following section I discuss how I developed a trusting relationship with participants.
In order to undertake this highly sensitive research I was aware that I needed to follow clear strategies and to ensure that these strategies were modified as needed in order to build rapport and to gain the trust of the participants (Lee 1993; Janesick 1998). From the start I realized the sensitivity of doing mental health research in Jordan (Al-Krenawi et al. 2004). From my experience as a mental health practitioner, I knew that the majority of individuals who have to access mental health clinics are worried about being stigmatized. I expected that some would use a clinic far from their home, or that some women would cover their faces in order not to be recognized in the clinic, even thought they did not usually dress in such a way. I also had experienced the fact that many gave a false name in order to conceal their family name in case someone would recognize the name, especially if they were from a well-known family or tribe.
Because I understand that the approach the researcher takes is significant in establishing trust (Fontana & Frey 1998), I adopted different approaches to introducing my research. I needed to clarify the purpose of the interview and to highlight my role as a researcher or a helper. When introducing the subject of the research I talked about my research role in general terms without directly talking about participant’s mental health problems. This was to make the atmosphere more comfortable (Padgett 1998).
It is interesting that even though I had such a ‘‘head start’’ in being Muslim, I encountered difficulties in gaining the trust of participants. Some were hesitant or refused to take part in the research. This is understandable as the subject of the
34 discussions was extremely sensitive, and participants were not familiar with me personally, or indeed with the whole idea of research. After enlisting the help of the mental health professionals at the clinic, who introduced me to their patients, I was more easily able to establish a trusting atmosphere. The mental health professionals also helped by explaining the subject of the research to their patients. This indirect approach presented me with a tension, as I wondered whether participants were agreeing to take part in the research because they were unable to refuse the requests of the mental health professionals who referred them to me.
It is interesting that although I spoke the same language as the participants, I sometimes found myself lost in a linguistic and subcultural forest. As Asselin (2003) suggests, familiarity with the culture does not mean total familiarity with all the various subcultures. To take couple of occasions as examples: I did not know that in certain villages a traditional marriage, called Zwaj Al Badal, means that a man will marry a girl from one family and a brother of the girl will marry the man’s sister. A female had to tell me about traditional Bedouin customs in marital disputes.
To ensure that they were willing participants in the true sene, I stressed their right to withdraw and not to talk about things that they preferred not to. In one incident, a female agreed to meet with me after a mental health nurse with whom she had a good professional relationship referred her. I noticed that the lady, who was from a well-known family, seemed to be worried. I commented that I would like to postpone the interview so that she would have a chance to think about whether or not she would like to take part in it. The lady called the next morning saying that she had family obligations. My sense that she was uncomfortable with the idea of being interviewed was probably confirmed by this response.
I noticed some participants appeared more enthusiastic about taking part in the research when I mentioned that I was doing the research as part of my PhD at an Australian University. My hypothesis is that this is due to the idea that things
35 coming from the West are seen to be more valuable, and also that people tend to have respect for those with higher education, as I was told on many occasions when I was discussing the subject with potential participants and with some mental health professionals at the clinic. Thus these two factors had a positive influence.
During the interviews, one of the challenges I constantly faced was that participants easily mixed my role of researcher with that of therapist. This problem is well described by Fontana and Frey (1998). Some participants seemed to agree to participate because they wanted to discuss or to clarify their psychological problems. Their knowledge that I had experience as a mental health professional seemed to contribute to this desires. As a clinician I recognised the need to restrain from engaging in the clinician role (Padgett 1998). I introduced myself as a researcher and explained my professional background. I explained the aims of the research and referred participants to mental health professionals at the Centre. I asked frequently about their feelings and if they would like to end the interview or continue with it. When appropriate I directed them to other venues in the clinic where they could get support.
In my view, the stress I placed on the participants’ right not to take part unless they were very clear they wanted to do so worked positively, and most individuals were willing and even enthusiastic about being part of the research.
During the interview I clarified my position as a learner. I felt the need to clarify the issue of power in the relationship between myself as a researcher and the participants as interviewees. From my experience as a social worker, and from contemporary literature (Fontana & Frey 1998; Fontana & Frey 2005; Grbich 1999), it is apparent that in many cases the relationships between individuals with mental health problems and mental health professionals is hierarchal. This is clearly addressed in much contemporary scholarship (Tseng 2004; Al Khayat 1997). Professionals, especially in government organizations, are considered to be superior, because they are the ones who provide the instructions and information.
36 Assuming the likelihood of this, I followed different strategies such as clarifying my role, emphasizing their right of withdrawing from the interview at any time, thoughtful seating, and the making of casual conversation. I tried to make it clear that I was a learner.
I stressed that I would maintain confidentiality. This was one of the important strategies at the beginning and throughout the interview. I sensed the participants needed to feel that I was non-judgmental towards them. This was very important in developing a trusting atmosphere wherein they could talk comfortably on sensitive and personal issues (Lee 1993). On occasions, when they were discussing something highly sensitive, some participants would point to the tape recorder and ask me to stop recording, even though they were happy for the subject to be included in my research. They simply did not want to have particular things tape recorded. My emphasis on respect and confidentiality encouraged individuals to share highly sensitive issues. Some, for example, revealed their real family name if they had been using a pseudonym. Others talked to me about domestic violence and sexuality, which are sensitive matters that are rarely discussed with anyone.
Denscombe (1998) suggests that if the subject being discussed involves sensitive and personal issues, the identity of the researcher becomes even more important. Participants often asked me about my background, my marital status, and whether I had children or not. I understood these questions were important, as I knew it would help to establish rapport if I were to respond to them. These questions served a purpose for the participants: they helped them decide what and what not to share with me. The questions, for example, about my family name helped them determine my background and whether I was related to people whom they knew. They used this strategy as a way to ensure confidentiality.
Fontana and Frey (1998), amongst other scholars, demonstrate how important gender is within the context of culture. As a female researcher I was aware that I needed to pay attention to how I conducted interviews with male participants; for
37 example, I kept the door open while interviewing male participants, as it is culturally not acceptable for males and females who are not relatives to be in a room with the door closed. I also sat behind the office desk when interviewing male participants. When a participant appeared to be religious (for example if they were wearing a beard or using special religious language) I did not initiate eye contact, nor did I shake hands. When talking to male participants I used a formal style of speech, knowing this would make them more comfortable and more willing to participate in the interview. On the other hand, when talking with females I was less formal and sat without a desk between us.
Content analysis
Content analysis is one of the research methods applied in this research. Krippendorff (2004) asserts that content analysis is an instrument which is applied to locate concepts, expressions, or language within a text. It is considered a systematic, logical tool. Krippendorff adds that this method enhances the possibilities of developing a better understanding of phenomena. In this process the researcher identifies themes, analyses meaning and the relationships between concepts, in order to understand the culture associated with the text. The text is usually coded into themes and then examined. Neuendorf (2002) asserts that content analysis is a popular method, which is due to the advancement of computer technology which has made the application of this methodology easier. Hsieh and Shannon (2005) state that content analysis is increasingly being used by researchers in the health area. They define content analysis as
a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns (2005 p. 1278).
For this research, I examined the content of the Qur’an (the holy book for Muslims) in order to identify themes in it which could be seen to suggest interpretations and perceptions of mental health problems in Islam. I selected The
38 Holy Qur’an, translated by Yusuf Ali, as the text for analysis as this translation was recommended by Islamic teachers who speak both Arabic and English. The two main books of the Hadith, Sahih Al-Bukhari and Sahih Muslim, both written in Arabic and translated into English, were selected as the two main resources of the narratives and traditions of the Prophet Muhammad.
The purpose of the content analysis was to identify the ways that causation and healing of mental health problems may be perceived within the Islamic traditions. The Qur’an and the Hadithic books were read word-by-word to identify the emergent themes which are related to mental health and mental health problems. The data was analysed by using NVivo software.
Data Analysis
To analyse the data I used NVivo software, a software program used in qualitative research which was developed by (QSR) Qualitative Solutions and Research International (Walsh 2003). The decision was made to use this software after consulting with colleagues, comparing different packages, and after attending a workshop on NVivo analysis which described its uses and benefits. This software was chosen over other programs because it has been modified to deal with some of the problems experienced in previous software (Welsh, 2002). It was considered to be a helpful, convenient tool. The program allows various documents to be saved and then connected. Thus one of the important benefits of using NVivo is the possibility of relating and contrasting ideas within documents and themes.
The interviews were first translated from Arabic into English. I was helped by an academic who specializes in English literature and who speaks Arabic as his first language. This help was particularly important when translating expressions which are hard to translate because there is no corresponding English form of words to convey their meaning. I am aware that some of the meaning might have been lost in translation. This is especially so for proverbs or idioms.
39 The interviews then were imported into the NVivo software. The text was coded. I used open-coding by reviewing the data ‘‘word-by-word’’ and coding each paragraph, and from this I developed the themes. This thematic analysis was then refined and incorporated with the documentary data. Open-coding helped to identify and explore themes without enforcing pre-constructed ideas on the analysis (Grbich, 1999; Padgett 1998). The flexibility of NVivo allowed capturing, and linking of ideas. This is because of the possibility of connecting nodes and documents within the one project and between projects. There were hundreds of codes which were categorised into themes. The themes were also grouped into main themes and sub-themes. The texts of the Qur’an and the Hadith were also imported as projects, and then coded. These codes were also categorised into themes and sub-themes.
Summary
In this chapter I have described the research design and methodology, and outlined the issues related to ethics. As well as this I have reflected on the interviewing process and summarized the interviews. The research process took twelve months. Having commenced my literature analysis and developed my conceptual planning in Western Australia, I then spent six months in Jordan interviewing. I returned to Western Australia to undertake my content analysis of the Qur’an and the Hadith and to consult with Islamic scholars. In the next chapter, I will discuss the issues of relating to culture and mental health problems.
40
CHAPTER THREE
CULTURE AND MENTAL HEALTH: UNIVERSAL CHALLENGES
In this chapter I address the issues related to culture and mental health, and focus on the difficulties in defining culture, mental health, and mental health problems. I propose that it is important to adopt a flexible approach to these terms, and I reflect on the historical developments associated with cultural studies, which have influenced contemporary scholarship concerned with culture and mental health. I also discuss how the review of the literature helped me to understand issues related to the application of western-based mental health approaches in non-western societies. In this research I propose the use of the term ‘‘cultural mental health’’ rather than transcultural mental health, or cross-cultural mental health. In the course of doing this I will also present an alternative language for describing the outcome of this scholarship. Prior to developing this I will provide a brief overview of the historical development of scholarship in what is currently termed either cross-cultural mental health, transcultural mental health, or cultural psychiatry. Many scholars now address the need to change approaches within the mental health field when dealing with people from non-western backgrounds, and I examine some of this scholarly work. I consider the need to find more flexible approaches to intervention in mental health problems in non-western societies.
It is a truism to say that culture influences the way mental health problems arise and are conceptualized. Culture affects the ways in which individuals present their symptoms, the help-seeking process, and ways of recognizing, labelling, and classifying emotional distress (Helman 2000; Ng 1997; Zlatanovic 1998). Culture also influences the way in which distress is experienced, understood, expressed and
41 responded to within a society and the ways that people interpret stress, the psychological, the biological, the religious, the socio-moral and the supernatural (Zlatanovic 1998). The cultural background of a person is seen by most writers to guide various aspects of that individual’s ways of living. The background is important as it influences people’s beliefs, patterns of behaviour, expressions, religious rituals, family structure, dress code, diet, concepts of time and space, and their attitudes towards the distress experience and pain. It also provides criteria for making choices (Helman 2000). Cultural background also informs individuals’ way of perceiving the world around them, and influences how they respond to it emotionally. It guides them to behave in certain ways towards others, as well as towards natural and supernatural forces, if these are a component of their identified repertoire. To sum up, paraphrasing the words of Tseng and Streltzer (2004), the concept of culture consists of inherited explicit and implicit directions that influence individuals within a specific society. Berry, Poortinga and Pandey (1997) assert that in order to understand culture and mental health there is a need to discuss some of the important terms which are related to the area. On the other hand, Bracken (2003) and Lewis (2000) argue that in a postmodern world finding precise definitions is a complicated task. Terms are variously applied according to their contextual framework. In the following I will discuss some of the important terms in relation to culture and mental health, and describe some of the complexity in their usage.
Culture
Many scholars, such as Jayasuriya (1992), Marsella and Yamada (2000) and Triandis (1996) assert strongly that, in order to be able to understand mental health problems, we need to understand the structured aspects in the cultural context and the concept of culture itself. The concept of culture is an important subject of debate in anthropological studies (Helman 2000), sociology (Aneshensel & Phelan 1999a), psychology (Berry, Saraswathi, Dasen 1997a; Berry et al. 1997) and psychiatry (Kleinman 1980). Despite the emphasis in the literature on the
42 importance of understanding this concept, many authors, such as Bhugra and Mastrogianni (2004) and Tseng (2003) tell us that writers in cultural studies have not provided a solution to the understanding of culture. Fernando (2002) notes that the difficulties in defining culture are in part reflected in the variety of ways the term has been used among scholars.
Al-Issa (1995) and Fernando (2002) acknowledge that the concept of culture has changed quite dramatically since it was introduced by anthropologists. Anthropological research was the first to use the term ‘‘culture’’ with reference to native, uncivilized group practices. Al-Issa continues to clarify that the term ‘‘culture’’ was used in anthropology to refer to tribal tradition. It was used to indicate, as Kleinman (2004) explains, the shared characteristics and ways of life of a group of people or a society. Kleinman continues to argue that adopting such an approach to conceptualizing culture create a problem as the term implied a static organism. and it seemed that this conceptualization did not take in account the variability in culture. The early concept of culture overlooked the possibility of variations within the cultural groups.
Culture has increasingly been considered, as Munroe and Munroe discuss, to be ‘‘a conceptual structure or system of ideas’’ (1997 p. 73). They argue that not all aspects of the system can be represented or expressed by individuals in one society. They also suggest that the influence of culture takes various forms and levels. Brown et al. (1999) describe culture as being ‘‘unbounded’’, and suggest that an individual from one ethnic background or social status could be influenced by more than one culture. For example, an individual could be influenced by his culture of origin as well as other general culture. Brown et al. (1999) emphasize that when reflecting on the term culture it is important to consider it as a dynamic concept, one which characterizes the way individuals perceive themselves in the context of their social surroundings, and which influences their ways of functioning. Other authors such as Hughes and Okpaku (1998) and El-Islam (1998)
43 stress the strong influence of the social interaction of individuals on their thoughts, behaviour, values, and traditions.
The majority of the definitions denote culture as the accumulation of subjective and objective aspects of human experience. Al-Issa (1995) and Pierce et al. (1999) describe culture as the subjective aspects are seen to relate to the values, belief systems and traditions shared by a group of people. On the other hand, objective aspects relate to the physical environment such as that represented in the built environment. Brown et al. (1999) and Helman (2000) argue that by its symbols, language, art and rituals, culture accommodates both biological and psychological needs as well as facilitating the transition of these needs from generation to generation. The latter author describes culture as an ‘‘inherited lens’’ which directs individuals living within a society. He describes being raised in a society as a form of ‘‘enculturation’’, and suggests that in the process of enculturation, individuals gradually adopt a ‘‘cultural lens’’. These subsequent shared beliefs and perceptions, he says, are important in preserving group cohesion and the transference of cultural values to the subsequent generations. Helman continues to assert that the transmitted culture is dynamic and adaptable, and that culture is a system with flexible characteristics. In this cultural system, he argues, individuals tend to recognize their identity and re-arrange their values.
A postmodern perspective of culture conceptualizes it not to be static or related to individuals, but rather something dynamic and relevant to the power in relationships. It views culture within its political, and historical, context. Of relevance in this respect is the research of Said (1994), who emphasizes the importance of analysing the history of the relationship between the imperial power and the colonized society, which he says shapes the conception of culture. He also suggests the importance of the relations between the concept of culture and globalization.
In general, as Fernando indicates:
44 culture is seen today as something that cannot be defined, as something living, dynamic, and changing – a flexible system of values and worldviews that people live by, a system which defines identities and negotiates their lives (Fernando 2002, p. 16).
Bhugra and Mastrogianni (2004) and Kirmayer and Minas (2000) assert that in the modern globalized world culture is considered by most scholars to be dynamic, and to result from collective communication between individuals, groups, and society and from interconnectedness among cultures. Paraphrasing the words of Tseng (2001), it is a process that is actively transforming. This, as most scholars emphasize, a useful contemporary expansion of the term in a period of world history in which the world is undergoing increasing globalization (Kleinman & Kleinman 1999; Bhugra & Mastrogianni 2004; Kirmayer & Minas 2000).
Mental health
The definition of mental health is probably as problematic as that of culture. As suggested by Helman (2000), concepts of mental health vary across cultures. Some writers describe mental health as the absence of mental illness. Jayasuriya, Sang, Fielding 1992; Helman 2000). Others such as Swartz (1998 p. 10) argue that the term ‘‘health’’ does not indicate ‘‘the absence of disease or infirmity, but a positive state of physical, mental, and social well-being’’. This concept of mental health is ‘‘inclusive in the term health’’.
It is commonly accepted by many scholars that health is more than an absence of disordered symptoms. However, endeavours to define the term mental health as the absence of mental health problems have not been successful, and are in many cases seen to be puzzling by writes such as Jayasuriya, Sang, and Fielding (1992), and Helman (2000). Mental health is described by Fernando (2002) as an ideal state of mind, which enables a person to function reasonably within the norms of a group. Some writers also refer to mental health as ‘‘quality of life’’. This, however, as Jayasuriya (1992) states, is an unclear expression, which is hard to implement for
45 measurement purposes on either national or international levels. Importantly, the World Health Organization has defined mental health as
a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Helman 2000, p. 84).
The subject of the domination of western philosophy in conceptualizing mental health has been the subject of discussions by authors such as Marsella and White (1984) and Kleinman (1980) who suggest that the adoption of western reductionist philosophy left many unresolved issues to deal with in the realm of mental health. They assert that the tendency to deal with the issue of mental health by dividing it into smaller parts and dealing with each part by a separate approach led to losing sight of a holistic view of mental health. More recent writings discuss the same problem (Fabrega 2001; Kleinman 2006; Marsella & Yamada 2000; Bhugra & Bhui 2002; Sashidharan 2001). Helman (2000) capitalizes on this idea of lack of holistic approach and compared concepts of health in western and non-western societies. He argues that in traditional societies, health is acquired when there is a balance between the individual and other individuals, the environment, and the supernatural. Any disturbance of the balance, he explains, will result in physical and emotional problems. Helman continues this line of thinking by arguing that the definition of health in industrialized societies tends to be less inclusive of factors such as the supernatural, and yet, he notes, this varies depending on social class but it does include physical, psychological and behavioural elements.
It is clear that the term ‘‘mental health’’ is subject to various interpretations. According to some writers, reaching mental health does not only depend on medical or psychological aspects but also religious and ethical ones (Fallot 1998; Schumaker 1992). Swartz (1998) argues that the concept of mental health is contested not only among mental health practitioners, but also is seen differently among individuals with different backgrounds. For example, he says, a problem
46 defined by a mental health professional as a mood disorder may be considered by an individual as a spiritual problem.
Mental health problems
The concept of mental health problems is also considered by many scholars to be vague, difficult to define, and contradictory (Lefley 1999; Schumaker 2001; Fabrega 2001; Mechanic 1999). The latter author suggests that mental health professionals’ main goal is to reach a united agreement on the characteristics of disorders. Fernando (2002) suggests that the definition of mental health problems, however, is controlled and treated by the mental health profession as a scientific system (Fernando 2002). Jayasuriya, Sang, and Fielding. (1992) argue that the debates about the meaning of mental health problems are further complicated by the debates and critiques of psychiatry which have been led by writers such as Szasz (1987).
Many scholars claim that health and mental health are largely conceptualized within the western model to be best understood within a medical/disease framework (Littlewood 2001; Prince & Tcheng-Laroche 1987; Mechanic 1999). Jayasuriya (1992) explains that within this framework a mental disorder is symptomatic of a ‘faulty machine’. A number of writers, however, warn us that what is considered to be an illness in one culture might not be considered as such in another. Theses scholars argue that in traditional cultures some of what is considered illness is handled traditionally without any labelling (Zlatanovic 1998; Murthy & Wig 2002; Koss-Chioino 2000; Lefley, Sandover & Charles 1998).
Mechanic (1999 p. 12) suggests that mental health problems arise ‘when the individual’s thought processes, feelings, or behaviours deviate from usual expectations or experience and the person affected or others in the community define it as a problem that requires intervention’. He adds that the sociological
47 perspective of a mental health problem is that it involves a strange act which is not understandable by others. Thus he says, behaviours for which an observer cannot find the motivation are categorized as ‘crazy’, and that people tend to discriminate between ‘bad’ behaviours and ‘sick’ behaviours. The sick act is when the motivation has no apparent logic behind it, for example, when an individual steals because of his poverty, people tend to describe the act as ‘bad’, whereas the same offence by a wealthy man is most likely to be described as ‘sick’.
Mechanic (1999) and Crossley (1998) claim that the conceptualization of mental health problems by a medical approach was criticized by the anti-psychiatry movement. According to the analysis of some of the writers in this movement, the notion of a mental disorder being a disease led to misdiagnosis and further, its underlying goal was that of social control. According to Szasz (1987), one of the main leaders of the anti-psychiatry movement, mental health problems cannot be conceptualized as diseases. Crossley (1998) argues that although the anti- psychiatry movement was questioned by many, and the critique led to a more realistic view of psychiatry and to the nature of mental disorders, its impact continues to be felt.
It has become apparent that many contemporary scholars and mental health practitioners acknowledge that, in order to understand mental health problems, it is important not to employ the medical-biological perspective or the cultural- anthropological perspective in isolation (Saravanan 2002; Al-Issa 1995b). Some writers such as Fabrega (2001) argue that the conceptualization of mental health problems must involve historical, political, economic and cultural analysis and perspectives.
In summary, in contemporary professional scholarship, mental health problems would at least be broadly accepted to be defined as the states in which the person’s functioning is perceived to be not right either by the individual themselves or by others close to them. Needless to say, and as Jayasuriya, Sang and Fielding (1992)
48 assert, even this broad definition raises the theoretical question of how to distinguish between normal and abnormal.
Culture and mental health
Writers such as Tseng (2001), Al-Issa (1995a), Okpaku (2002), Zlatanovic (1998), Berry, Dasen and Saraswathi (1997a), Dein and Lipsedge (1998), Hughes and Okpaku (1998), Okasha et al. (2002), Prince (1993), Schumaker (1996), and Lewis-Fernandez and Kleinman (1995) have addressed the area of culture and mental health and its relation to concerns with human behaviours, tendencies, values, perceptions, attitudes, folklore, religious conventions, the interests of general human conduct, and the clinical management of mental health problems of people. This approach called the cultural approach has been a valuable source for psychiatry in terms of theorizing, diagnosing, and providing insight into mental health interventions and preventive measures.
In the following sections, I will summarize briefly the historical development of scholarship in the area of culture and mental health.
Historical development
From their early emergence, the mental health professions acknowledged variations in the experience of mental health problems among different groups (Bains 2005; Triandis 1995). Tseng (2001a) asserts that even at the beginning of the nineteenth century attention was being given to the differences in behaviours which were then described as ‘peculiar’ and ‘exotic’. Early scholars at the time observed that mental health problems increased with the advancement of civilization, and were fewer within communities where there were less stressful lifestyles. Prince, Okpaku and Merkel (1998) suggest that the interest in culture started in the late nineteenth century when psychiatrists had the chance to encounter different cultures in European colonies.
49 Fernando (2002) and Bains (2005) note that the growing interest in culture and mental health began at the start of the twentieth century. They suggest that early investigations were initiated by anthropological studies, and later this area became known as cultural psychiatry. These early studies, which compared European societies with traditional societies, were later called ‘cross-cultural psychiatry’ or ‘comparative psychiatry’. According to Fernando (2002) and Al-Issa (1995a), these early cultural analyses were initiated by Kraepelin in 1904. However, as Fernando (2002) suggests, these writings failed to address the problems of race and ethnicity. More recent approaches to cultural comparison in mental health use the term ‘transcultural psychiatry’ and include within this the areas of cultural psychiatry and cross-cultural comparative psychiatry. Okpaku (1998) argues that the active debates among psychiatrists and social scientists of this period raised many questions about definition and methodology which consequently contributed to the development of the field.
Tseng (2003) points out that several studies of mental health problems were conducted by anthropologists in the 1930s. He further asserts that the Freudian school’s theoretical input in the 1930s influenced some of these studies in anthropology. Sigmund Freud presented in his book Civilization and its Discontents an analysis of the relationship between the repression of ‘civilization’ and the development of neurosis. The main conclusion of Freud’s analysis was that the industrialised, civilised lifestyle, which is unlike the traditional lifestyle, causes stress and leads to mental health problems. However, Al-Issa (1995a) observes that not long after Freud’s seminal work further research suggested that mental disorders were present in traditional cultures too, and the research in the area increased.
The year 1955 saw the emergence of transcultural psychiatry as a recognized discipline. This is recorded by Prince, Okpaku and Merkel (1998) to have occurred at McGill University in Montreal when the psychoanalyst Wittkower drew the attention of professionals and scholars to the pivotal place of cultural elements in
50 mental health. Prince says that Wittkower managed to establish the transcultural psychiatric Research Review Journal, the first journal to appear at that time in this area (Prince, Okpaku & Merkel 1998). Since then, of course, as Tseng (2001a) asserts, a large number of journals, programs, and conferences have been established that address cultural issues and mental health.
Contemporary issues in mental health
The need to develop a greater awareness and understanding of the cultural elements of mental health when dealing with and promoting mental health services has increasingly been recognized by mental health professionals and scholars (Al- Issa 1995b; Bhugra & Bhui 2001; Leininger 1987; Littlewood 2000; Okasha 1999; Okpaku 1998; Pedersen, Sartorius, Marsella 1984). When discussing contemporary issues related to the field, these scholars acknowledge various challenges which need to be addressed by the mental health professions when dealing with the mental health issues of non-western societies. Some of these problems are related to terms; others relate to how the mental health professions are best applied in non- western societies.
1. The problems with the term
As indicated earlier, one of the important scholarly discussions concerns the subject of terminology. It seems that there is no uniformly accepted term for the field which is concerned with mental health issues and culture. The relation between culture and mental health focuses on an area that has been recognized by various terms: transcultural psychiatry (Al-Issa 1995a), transcultural mental health, ‘cross-cultural psychiatry’, and ‘cultural psychiatry’ (Jayasuriya, Sang & Fielding 1992). Most researchers use the term cultural psychiatry, which is considered to be more comprehensive. The use of the term ‘culture’, unlike other terms, is not confined to any particular methodology (Tseng 2001a).
51 In this research I have adopted the term ‘cultural mental health’ when talking of the intersection of mental health and culture, for the following reasons. The term cultural mental health indicates the inclusion not only of psychiatry, but also of other disciplines, such as: anthropology; cross-cultural psychology (Berry, Dasen & Saraswathi 1997a; Tseng 2003); nursing (Leininger 2002); sociology (Aneshensel & Phelan 1999a) and social work (Al-Krenawi & Graham 1999). All these disciplines have contributed to the area of mental health. Also, the concept of mental health as many, such as Jayasuriya, Sang and Fielding (1992) indicate, means more than the absence of mental disorders. The term ‘mental health’, rather than ‘psychiatry’, indicates the inclusion of other related areas, which are increasingly becoming the focus of attention for mental health professionals (Littlewood 1996). In other words, and as Swartz (1998) argues, the boundaries of mental health problems can be extended to incorporate other social, cultural, and psychological problems.
There is a growing tendency towards preventing and dealing with social problems within clinical settings. Dealing with such problems from the clinical perspective is believed to be beneficial in helping people to come to terms with their concerns and difficulties. Problems like ‘bereavement’, ‘incest’, ‘witnessing disaster’, ‘sexual dissatisfaction’, ‘inclination to theft’, ‘violence’, ‘greed’, and ‘the stress of urban life’ could all be perceived as being of interest to mental health professionals (Littlewood 1996). Fernando (2002) asserts that marriage and family problems, as well as other forms of distress and misbehaviour, all seem to have fallen within the area of psychiatry, and belong in the much larger framework called mental health; that is, they are broader than psychiatry.
Reports in World Mental Health introduced various social problems as being of interest to those in the mental health area. These included problems such as ‘poverty’, ‘substance abuse’, ‘dislocation’, and ‘women’s oppression’ in developing countries (Swartz 1998). All these problems are also of interest to mental health. Dealing with such problems is supposedly beneficial in helping to
52 come to terms with people’s concerns and difficulties, all within a medical perspective (Littlewood 1996 p. 245).
2. Lack of applicability of the mental health profession in non-western societies
There are a number of themes that emerge from the preceding analysis of historical and contemporary scholarship on culture and mental health. These themes are centred around a problem that has already been enunciated, namely the apparent unsuitability of western approaches when dealing with non-western societies in diverse societies or in developing countries. As has already been indicated, a number of scholars confirm that the influence of western cultures is dominant in the area of mental health, and that these approaches have proven not suitable to be applied to the assessment and treatment of mental health problems in non-western societies (Prince et al. 1998; Kleinman 2004). In the following section I explore some of the difficulties associated with this.
Authors such as Han and Liu (2005), Fan (1999), Davidson et al. (2004), Ghazali (2004), Halabi (2005) and Fong (2004) argue, for example, that individuals from non-western backgrounds do not always access mental health services in multicultural settings. This apparent reluctance is of concern, given the high likelihood of mental health problems caused by voluntary or involuntary migration. Many individuals are affected with mental health problems due to the experience of being a refugee or migrant. Patel (1996), Fong (2004) and Davidson et al. (2004) assert that being a refugee or migrant affects mental health and causes emotional distress. This is due to the facing of many difficulties such as: settling in the new environment, having to deal with language barriers, and the experience of prejudice and bias. Al-Issa (1995a) and Swartz (1998) further claim that the hypothesis is that migrant status (being a refugee or immigrant) affects mental health and that refugees experience more emotional distress than immigrants. They further note that most migration to western societies is from Asia, Africa and Latin America.
53 These are countries that have been previously colonized and exposed to various prejudices and problems.
Murthy and Wig (2002), Desjarlais et al. (1995), Kamal (1995), Bose (1997) and Pedersen (1984) argue that the application of western-based mental health services in developing countries is no less problematic than their application in diverse societies. In developing countires, the problem is seen as the application of western mental health approaches to people without consideration of their views. One of the main challenges which mental health professionals from traditional societies face is the application of western methods and interventions in their traditional societies. Marsella and Hugginbotham examined the same issue more than twenty years ago (1984) and they argued:
…in spite of the many limitations and inadequacies that characterized western empiricist approaches to mental health, we have not been hesitant to import it to non-Western cultural milieus. Every day, western mental health concepts, methods, facility designs and professional training techniques are being fostered, encouraged, and promoted as the answer to the non-western world’s mental health problems, regardless of the many pernicious effects cited in Pedersen, Sartorius, Marsella (1984 p. 176).
Tseng (2001) has noted the historical roots of this problem by arguing that since World War II a considerable number of non-western mental health professionals have received their training in developed societies. Murthy and Wig (2002), Jayasuriya (1988) and Kamal (1995) talk about the tendency in developing countries to ‘transfer’ knowledge and strategies, including mental health approaches and systems, from the industrialized, advanced societies to a different cultural system. This, as they say, is done without taking into consideration the extent to which these imported approaches and knowledge suit the traditional culture. These authors comment strongly that rushing in to follow the western reductionist model has not allowed the suitability of the services to individuals in developing societies to be adequately examined. This usually, as Fanon and Haddour (2006) also explain, is a reflection of what could be called a dependency
54 syndrome, which represents the same tendency of the political and economical system in third world societies.
Pedersen et al. (1984), on the other hand, state that the difficulties associated with the professional, social, economic and political situations in traditional societies make the task of implementation of theories of mental health even more complicated. Scholars observe that, for example, mental health curricula in Arabic countries such as Jordan (Al-Krenawi , Graham & Kandah 2000), Egypt (El- Gawad et al. 1995), or Algeria (Al-Issa 2000b) are almost an exact duplication of those found in the West. Most psychiatrists are trained in western countries; books and treatment methods are also imported as are pharmacological treatments (El- Gawad et al. 1995; Al-Issa 2000a).
Scholars have discussed many characteristics which contribute to the difficulties in applying the western model in non-western societies. Some, such as Fernando (2002), Dossey (1999) and Okpaku (1998), have noted that the western-based model has lost sight of the holistic view of human nature. Swartz (1998) argues that medicine and psychiatry primarily originated from the western belief in the separation between body and mind, as well as the observer and the observed. He further asserts that within this western model there is a notion that by studying each part as a separate entity we will be able to understand the function of the whole body, that is when we gather the sum of the knowledge of each part, we will be able to make sense of the whole. On the other hand, Bose (1997) indicates that the sense of interconnectedness between the body, mind, self and others that exists in non-western cultures makes the application of such a western model a difficult task. In these non-western societies there is often a stress on the importance of spiritual and social aspects in relation to causations of and intervention in mental health problems. Kleinman (1999) asserts the same point by noting that the mental health profession focuses on the disease as biological, and not the illness, which consider the whole unique experience of a person. They state that managed care constraints, litigation and growing regulatory pressures have compromized
55 communication and trust between physicians and patients. This, along with the surge in technologic development, has driven the medical system even further towards a ‘disease-based’ approach to health care that views individuals as cases and undervalues the sociocultural and humanistic aspect of patient care.
Kleinman also argues that the older approaches of transcultural mental health that originated in western cultures imposed the concept of ‘universality’ rather than taking into account the consideration of ‘differences’ (Kleinman 1980). Jayasuriya, Sang and Fielding (1992) argue that the ‘universality’ of cross-cultural studies refers to the use of tight western categories and approaches in examining psychological phenomena cross-culturally. Kleinman (1980) asserts that the mental health profession was not successful in answering the question of the dialectical relationship between the biological side and the social side of the society.
Some scholars such as Bhugra and Bhui (2002), Fernando (2002), Swartz (1998), and Littlewood (1996), draw attention to what they label the problem of prejudice and bias in the mental health profession. The bias embedded in western-based psychiatry, as they strongly claim, contributes to its lack of applicability within non-western cultures. These scholars have criticized the profession for its historical association with racism, for not integrating the insights of more radical approaches, and for being based on biased views and interpretations of mental disorders. Littlewood further argues that there is a close association between western psychiatry and ‘imperialism’. Both, he suggests, emerged simultaneously and were based on similar values and principles. Fabrega (2001), Jadhav (1996) and Prince et al. (1998) assert strongly that some of the features of the bias embedded in the mental health profession is evident in the tendency by psychiatrists to impose western medical knowledge and diagnostic criteria on non-western cultures. Fernando (2002 p. 85) offers an example in which he shows how healing is neither well understood nor well conceptualized in the reductionist medical model. He suggests that when an individual heals without defined scientific reasons ‘understandable within the reach of the reductionism idioms’, the healing is
56 attributed to reasons such as the ‘placebo affect’ or to ‘spontaneous remission’. He says that the reductionist western medical approach also adds difficulties to the distinction between the psyche and the soma. The distinction, Fernando says, between the mind and the body led to the development of the so-called psychosomatic field.
Another example of the biased views in the mental health profession is given by Swartz (1998), who explains that the western model of the conception of various syndromes is taken to be central, with symptoms from other cultures being considered merely exotic, cultural-bound syndromes. He argues that western psychiatry acts as though these symptoms are only variations of universal distress. In other words, symptoms not equivalent to the western perception or diagnosis of mental health disorders are considered ‘cultural-bound syndromes’. Swartz argues that cultural-bound syndromes can be found within western societies as well as within traditional societies. Symptoms such as ‘shoplifting’, ‘agoraphobia’, ‘exhibitionism’, and ‘domestic sieges’ are some of the disorders that are suggests could be culturally bound.
Psychotherapy and counselling are seen as a representation of the lack of suitability of western mental health approaches to non-western cultures by a number of authors (Bemak, Chung & Pedersen 2003; Saleh 1989; Lopez-Baez 2006; Mass & Al-Krenawi 1994; Pedersen et al. 1996; Soliman 1991). Those scholars consider that these practices originated in western Judaeo-Christian culture, and are based on western values of individualism and self-determination, independency and assertiveness. All of these, and many other authors argue strongly that these cultural approaches are not always effective on other non-western cultures. When talking about the available experience on non-Western societies, some authors such as Al-Issa (2000a) and Swartz (1998) doubt even the accuracy of this accumulated knowledge. They are critical and say that some of the research conducted on non- western societies by some western scholars was motivated more by curiosity rather
57 than the practicality of the research. This kind of research was not aimed at enriching the mental health profession.
3. Optimism about cultural mental health
In spite of the negativity identified by many scholars, there are some positive aspects in the field. As Tseng (2001), Bose (1997) and Okpaku (1998) observe, the work and participation of many mental health scholars has contributed to a clearer, more robust conception of cultural mental health, and attracted attention to the lack of suitability and domination of the western approaches to mental health in relation to non-western societies. Okpaku (1998) states that the increase in knowledge in this area has led to greater influence of cultural mental health theory, and that this has, as a consequence, transferred the ‘old psychiatry’, to what he calls the ‘new psychiatry’. Some scholars, such as Fernando (2002) and Bates (1977) for example, address the positive consequences of applying the scientific medical model. They assert that this model has no doubt worked positively in terms of developing medical knowledge. Swartz (1998) also drew a more positive picture of the contemporary mental health services, arguing that the notion of the separation of the body and the mind is increasingly becoming less popular, even within the western model of treatment, and suggesting that the western medical approach to assessment and treatment is becoming more advanced and aware of the importance of the social sciences as a source of guidance.
Fernando (2002) and Swartz (1998) comment that a gradual transference from biased western views was introduced by scholars in the 1980s, and was initiated by professionals from non-western backgrounds who challenged many misconceptions in psychiatry.
Another positive feature observed by contemporary scholarship is that many researchers in the West also started calling for investing cultural perception in the application of psychiatry, taking into consideration the social realities of the
58 appointed culture. They suggest that until recently the attention of research in mental health was directed towards the emic approach rather than the etic when analysing or dealing with cultural issues. They observe that there has been an increased interest in the perception and categorization of illness in the light of the reports of the subjective experience of the various cultural and indigenous groups. Scholars such as Kleinman (1980) and Kirmayer and Robbins (1991) observe a strong move away from what they call old orthodox psychiatry.
As indicated earlier, Kleinman (1980) was one of the first psychiatrists who criticized the universalist approach to mental health and considered it to be ‘old psychiatry’. Kleinman introduced the relativist approach to mental health practice, and argued that the western psychiatry model was being inappropriately implemented across cultures. He also argued that this was being done without appreciating other aspects of the human experience in relation to mental health problems. In the view of Swartz (1998) mental health professionals have focused their attention on only a very narrow aspect of the problems they encounter in the experience of people they are attempting to help.
The relativist approach was introduced by Kleinman (1980) as a response to what he called the applied universalist model. This approach can be seen as a reflection of an emic analytical method, where culture is examined from within. Both the ‘etic’ approach, which refers to a westernized universalist approach in perceiving life events and phenomena, and the ‘emic’ approach, which takes a main interest in the individual’s mental health experiences, were incorporated into research and scholarship and this produced a richer contextualization of mental health problems as they were experienced by individuals. Pedersen et al. (1984) suggested that appreciating the cultural context of mental health reduces the chances of ‘cultural encapsulation’ and the negative influence of personal biases in the relationship of mental health professionals with individuals from various cultures who have mental health problems.
59 Some scholars have suggested that the relativist approach to mental health problems also assists professionals in recognizing that there is a ‘collective’ element that may contribute to disorders. Aspects of this collective element might be related to political, social and cultural issues, and not directly to medical causes. Littlewood (1990) and Fabrega (2001), say, in other words, that what an individual suffers from may not be a disease but an illness. Jayasuriya (1992) claims that this distinction between disease and illness has greatly benefited cultural studies, which tend to focus on illness and not on disease. Swartz (1998) suggests that the relativist approach has contributed to the heritage of western psychiatry in spite of the criticism of its lack of practicality within the clinical model.
The new scholarship practice should, as Prince, Okpaku and Merkel (1998) point out, consider the meanings in specific cultures, and the comparison with certain behaviours within other cultures, and by this means reaching a better assessment and understanding of the extent of the universality of human behaviour. This new approach has, as Prince, Okpaku and Merkel (1998 p. 3) suggest, already identified practices which have never been successful in addressing the question of the dialectical relationship between the biological and the social sides of society. Scholarship in cultural mental health has, according to Prince, Okpaku, Merkel (1998), had to acknowledge the accumulative effect and impact of a diverse range of philosophical sociological and psychological contributors over many years. These, they argue, have come from a range of disciplines. Examples are Foucault and his writings in the area of medical history; the psychological discussions of the commonality of ‘emotions’ and ‘cognitions’; ‘the sociology of knowledge’; and the different interdisciplinary critical philosophies such as Marxism, semiotics, structuralism, ethno-methodology, deconstructionism, and the writings of Wittgenstein and Lacan. The main argument of these theories is that there is difficulty in separating theory and observation, fact and values, the objective and the subjective.
60 Bhugra and Mastrogianni (2004) anticipate that many more positive outcomes will be achieved in mental health practices as a result of globalization, which they see as the new alternative to universalization. Adding to this observation, Lewis (2000), considers, as a consequence of the influence of postmodernism, there will be more positive developments in the mental health area. He argues that the approaches and findings of other areas of research will be reflected in mental health in general. He adds that the inclusion of wider range of disciplines in mental health scholarship will contribute to the transfer from the old ways of interventions to a more practical collective orientation, in which there is greater inclusion of ethical, political, and cultural issues.
Williams and Healy (2001 p. 2) offer much hope by saying that the emphasis on the study of culture is stressed by the necessity of professionals including cultural issues as part of their ethical obligations. They argue that while health beliefs may be important in terms of their relationship to subsequent behaviour, recent moves towards more patient-centred services suggest that the validation of individuals’ beliefs, are also important in their own right.
4. The struggle to find the right place for culture
In spite of the positive developments in the area of culture and mental health, there has been an increased realization of the difficulties associated with the application of mental health approaches to traditional and non-western cultures at the diagnostic, prevention and intervention levels (Fernando 2002; Tseng 2001a). The application of western methods and interventions in traditional societies continues to be one of the main challenges mental health professionals from non-western backgrounds face (Kleinman 1980; Kleinman 2001). Lewis (2000) notes that there is a strong body of opinion to indicate that there is an ongoing tendency to concentrate on scientific approaches whilst paying lip service to cultural values.
61 Fernando (2002) discusses the urgency of developing an understanding of the issues of prejudice when dealing with mental health issues. He urges this because the political situation is changing all over the world, and he draws attention to issues such as the westernization of Asian and African societies, and the need for many to identify with their ethnicity. There is a need, he argues, for a different approach to mental health, one which does not derive from the old power structures of the world. He goes on to suggest that this new approach to the study of mental health problems and mental health needs to consider the experiences of other cultures, such as black or Asian, and must not be based solely upon western knowledge (Fernando 2002). Al-Issa (2000a), for example, argues that psychiatry in Muslim societies is facing various problems, mainly the challenge of finding an identity within the strong influence of westernized intellectual psychiatry.
Kleinman (1999) has urged us to build better ways of interacting and dealing with mental health problems, and they suggest that factors such as the rapid changes around the world on the social, political and economic levels, the changes to the cultural and information exchanges, ‘urbanization’, styles of clothing and ways of living, the increased interaction between the west and the east, and ‘cultural diffusion’, the move from one culture to another, must all be taken into account. Other factors, such as the growing numbers of voluntary or unwilling migrants, provide increasing evidence that the world is heading towards globalisation (Kleinman 1999; Okpaku 1998; Bhugra & Mastrogianni 2004) and this, as Fernando (2002) has argued, has taken over from earlier imperialism and colonialism as the dominant worldwide trend. I note that the literature on globalization is highly contested and is beyond the scope of this thesis.
According to Bhugra and Mastrogianni (2004), there are many downsides to globalization. Associated with these vast global social changes are sets of social problems that are intensifying. Street violence, alcohol abuse, illicit drug abuse, domestic abuse, and disintegrating slums, shanty towns and inner cities are in turn associated with mental and behavioural health problems: depression, post-
62 traumatic stress disorder, suicide, family instability, and psychological distress are all mentioned by authors (Bhugra & Mastrogianni 2004; Kleinman & Kleinman 1999). While Okpaku (1998) argues that these changes have increased the need for understanding the effect of culture on mental health issues (Okpaku 1998), Tseng (2001) and Kleinman and Kleinman (1999) highlight the need to better understand mental health problems in non-western cultures and societies. They also emphasize that working toward positive change also requires the development of better ways of preventing and applying solutions to mental health problems worldwide, rather than simply treating the disease in its local setting. The latter scholars urge mental health professionals to expand their knowledge and expertise in order to build a more productive, trusting relationship with individuals with mental health problems in this globalizing world. Fabrega (2001) and Tseng (2003) assert strongly that the need for a more culturally sensitive assessment and interventions worldwide is one of the major concerns for the mental health profession today. Using a postmodern analysis, Bracken (2003) and Laugharne (2004) highlight the need for a more careful understanding of the concepts of ‘knowledge’, ‘trust’, ‘power’ and ‘choice’ in the helping relationship as more culturally sensitive practice are developed.
Zlatanovic (1998) argues that for such a new approach to take hold in a culture, the elements which ultimately create the cultural systems and identity of one specific group must be considered. Mechanic (1999 p. 8) notes that some of these elements that need to be clarified are religion, ethnic background, and racial and national origins. This is he argues particularly urgent as nations throughout the world are becoming increasingly racially intermixed.
Summary
In this chapter I have given a brief overview of cultural mental health scholarship from the nineteenth century to the present day and I have proposed that, as researchers, scholars and practitioners, we are now experiencing a period of
63 uncertainty as we grapple with the implications of globalization and cultural exchange. In the next chapter I undertake an analysis of religion, and, centrally, argue that it is a factor which needs to be better understood in relation to the mental health profession.
64
CHAPTER FOUR
RELIGION AND MENTAL HEALTH
In this chapter, I describe and summarize the important nexus between religion and mental health as it has been addressed in the literature to date. The focus of the chapter is the history of this relationship (or non-relationship), and in exploring it I conclude there has been significant and longstanding negativity about the place of religion in mental health services among mental health practitioners and academics. It appears that this has been the case despite the work of a number of writers such as Larson (1998), Pargament (1997), Koenig (1990), McCullough and Larson (1998), Shafranske and Malony (1996), Schumaker (1992), Littlewood and Lipsedge (1998), Lefley (1991), Richards and Bergin (2000), Loewenthal (1997), Dorahy et al. (1997), Levin (1998), Hill (1999), George (2000), Prince (1992), Miller (2003), Dein (1997), Bhugra (1996) Weaver et al. (1998), Spilka (1986), Thoresen (1999), Dossey (1997), Wulff (1997), Zinnbauer and Pargament (1998), Ladd and Spilka (2002), who have all called for the appreciation of the role of religion in working with people with mental health problems. I also analyse some of the more recent literature that provides evidence of an emerging acceptance of the importance of religion by those working with people who have mental health problems.
Religion, as Pargament (1997) indicates, is increasingly considered an important source of understanding about human beings and their ways of coping with psychological problems. Religion and spiritual beliefs influence belief systems, the ways people act, and their responses to distressing experiences. Thus recent scholars such as Idler and George (1998), Pargament (1997), Hartog and Gow (2005) have recognized it as a rich context within which to interpret many mental health problems and to understand options for healing processes. Indeed, this
65 important contemporary research suggests that incorporating religious ethics and principles into clinical interventions is a prerequisite for achieving positive and effective results for those who have mental health problems. In this work, these authors assert that it is important at the outset to acknowledge that in many traditional cultures, religious, ethical and medical issues, including those relating to mental health, are mutually dependent. In spite of the growing importance placed by scholars and professionals on the significance of religion, there are still gaps in the literature and professional challenges in relation to mental health and religion.
One of the difficulties in exploring the relationship between religion and mental health is that both are broad concepts and their definitional boundaries are vague. I have already identified the difficulties inherent in using the terms ‘mental health’ and ‘mental health problems’. The literature on religion is similarly contested. For example, religion is sometimes regarded as synonymous with spirituality and sometimes as very different from it. The nuances of the problem of definition are addressed in this chapter, as are some of the challenges facing mental health professionals as they mediate the territory between mental health and mental illness and religion and spirituality. What I suggest at the close of this chapter is that the emerging view in the literature is that in denying the relevance of religion, professionals and scholars have created a gap which needs to be explored at the theoretical and the practical levels if we are to significantly improve mental health practice with individuals from various non-western cultural backgrounds.
Defining religion
Understanding the conception and the dimensions of religion and its various aspects is a challenging task. The conceptualizations of religion are presented variously in different studies (Hyman & Handal 2006; Hill & Pargament 2003; Pargament 1997; Richards & Bergin 2000b; Zinnbauer et al. 1997; Koenig 1998; Thoresen 1999). As Taylor, Chatters and Levin (2004), and Miller and Thoresen (2003) suggest, there are no fixed criteria or patterns which symbolize or
66 characterize the conceptions of religiosity. Carr (2000) takes this further by noting that the terms ‘spirituality’, ‘religion’ and ‘mental health’ are all controversial terms and each represents a large theme. Schumaker (1992) explains that, like the concept of mental health, religion and spirituality need to be perceived within their context, and within a collective framework.
Some scholars have discussed the historical origin of the concept of religion. Wulff (1997) discusses its origin by noting that Religio is the Latin source of the word ‘religion’. This term was used very early to indicate submission to a greater power. The significance of such submission was that in adopting special rituals one hopes to avoid the catastrophic. Smith explains another dimension of religion when he suggests that Religio also incorporates the perception that religion is mainly concerned with the inner feelings of individuals towards the greater power. Religio also indicates the activities undertaken in a sacred place aiming to worship a certain power. As Smith (1963), cited in Wulff (1997 p. 4), concludes, Religio indicates ‘something that one does, or that one feels deeply about, or that impinges on one’s will; exacting obedience or threatening disaster or offering reward or binding one into one’s community’. According to Wulff (1997), the term religion is now interpreted in a broader, more comprehensive manner. He suggests that the concept of religion no longer refers exclusively to the inner experiences, feelings, and activities of individuals, but also to the experience of others. It incorporates a collective perspective of values. Similarly, George et al. (2000) argue that collective identity is the main characteristic of religion.
When using the term religion, most scholars agree with the general proposition put by Thoresen (1999) and others, who propose that religion is a ‘social institution’ which is based on a structured philosophy, traditions, values aimed to foster the connection of individuals with the divine, the self, others, and the environment. Religion, according to Faiver, O'Brien and Ingersoll (2000 p. 155), means ‘rebinding’ or ‘a way of belonging to the whole’. Geerta (cited in Faiver 2000), defines religion as:
67 a system of symbols which acts to establish powerful, persuasive, and long- lasting moods and motivations by formulating conceptions for a general order of existence and clothing these conceptions with such an aura of factuality that the moods and motivations seem uniquely realistic (Faiver et al. 2000 p. 55).
Schumaker (1992 p. 6) suggests that definitions of religion have concentrated on many dimensions. He groups these under the ‘intrapersonal’, which defines religion as ‘a dialectical process between the mundane and the transcendent’, and the cognitive which relates to the inspirational influences and the ritual traditions. He suggests that some definitions remain concerned with limited views of the span of meanings for religion. He suggests that some, for example, might not consider as religious philosophies which do not posit a belief in the existence of God (Schumaker 1992).
Koenig, McCullough and Larson (2001), in the Hand Book of Religion and Health, summarize their view of religion by stating:
Religion is an organised system of beliefs, practices, rituals and symbols designed (a) to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality) and (b) to foster an understanding of one’s relationship and responsibility to others in living together in a community (McCullough and Larson. 2001, p. 8).
Religiousness can be described, as Miller and Thoresen (2003) have argued, as a ‘private’ or ‘public’ experience, in which an individual expresses devotion and commitment to following the values and practices of a religion. Koenig, McCullough and Larson (2001) describe religious commitment as a term loosely used to reflect a degree or level of religiosity; it attempts to capture how internally committed the person is to his or her religion. George et al. (2000) view religiousness as being equivalent to the term spirituality, as both seek to explore the ‘divine’. Religiousness, Zinnbauer et al. (1997) argue, can be categorized within various traditional beliefs systems – for example Judaism, Buddhism, Hinduism, Christianity, or Islam. They suggest that in general it is defined as a
68 process of thinking and believing in a supreme power, as well as the sum of worshipping activities aiming to connect people with this supreme power. Levin (2001) argues that the need for adopting religious beliefs is manifested variously among societies and communities. He further describes that being part of an organized religious community will have an impact on health, as the majority of religions promote values that organize human action in relation to health or illness. He suggest that some of these religious principles encourage or discourage certain behaviours which are related to health.
The problems with conceptualizing religion
Scholars such as George et al. (2000), Hackney and Sanders (2003), Hill et al. (2000), Hyman and Handal (2006), Larson, Milano and Lu (1998) and Thoresen, Harris and Oman (2001) assert that there are numerous challenges in defining religion. Wulf (1997), for example, notes that the move towards religious pluralism in contemporary society makes conceptualizing religion an even more difficult task than it was. He observes this emerging pluralism in the fact that there are now many individuals with different spiritual and religious orientations living within the one community. He also asserts that religious pluralism is essential to a postmodern perspective on culture contrasting this with the idea of modernity in which there is only one ‘face’ for reality in spite of the diversity of beliefs and values amongst peoples. Another challenge, as Thoresen (1999) and Schumaker (1992) argue, for conceptualizing and using the term is that religious perceptions, beliefs, and practices are unique to each individual. As Wilson, cited in Schumaker, suggests: ‘Religion is not a homogenous whole. Individuals who are religious in one respect might not be in another’ (Schumaker 1992 p. 5). The conceptualizing of religion is also influenced by the subjective experience of the person attempting to define religion (Miller & Thoresen 2003).
69 Spirituality versus religion
Many scholars, such as Carr (2000), Fallot (1998), George et al. (2000), Hill et al. (2000), Josephson (2000), Koenig (1998), Koss-Chioino (2004), Lockwood (1999) and Tan (2003), indicate that the concept of religion is further complicated by its interface with the concept of spirituality. Spirituality has been the subject of discussions by many scholars: Carr (2000), Canda and Furman (1999), Gallagher, Wadsworth and Stratton (2002), Hill (2000), Thoresen (2002), Baetz (2004), Dombeck (1987), Dossey (2001), George (2003), Hall (2004), Harris et al. (1999), Koenig (2002), Miller and Thoresen (1999), and Spilka (1986). According to Taylor, Chatters and Levin (2004) and Zinnbauer et al. (1997), the distinction between religiosity and spirituality is one of the most fundamental issues facing researchers and scholars of the sociology and psychology of religion. Koenig, McCullough, Larson (2001) noted that during a recent series of conferences in which sixty leading researchers and scientists in medicine, psychology, substance abuse and the neurosciences met and discussed issues related to religion and health, it was recorded that it was difficult to find definitions of religion and spirituality that were acceptable to everyone.
George et al. (2000) argues that the difficulties in differentiating between the terms religion and spirituality exist not only among professionals and researchers, but also among many individuals, who do not see any differences between being religious and being spiritual. He suggests that many people perceive themselves as being both. Some claim the distinction between the terms is artificial. Thoresen (1999) and George, Larson, and Koenig (2000) and Taylor, Chatters and Levin (2004) point out that each term is often linked to the other. They argue that drawing a distinction between religion and spirituality has proven difficult not only among lay people; scientists also use the terms interchangeably. They say, for example, that some researchers use the term ‘spirituality’ in the titles of their articles, while their focus proves to be on fairly standard indicators of religious participation such as church attendance.
70 What complicates the problem is what George et al. (2000) and Koenig et al. (2001) describe as the two terms having commonality as well as difference. Scholars such as Thoresen (1999) and Carr (2000) consider spirituality to be mostly connected with and to have emerged from religion. Carr (2000) and Miller and Thoresen (2003) point to the common characteristics between religiosity and spirituality. Whilst George et al. (2000) assert that religion is associated with a certain organization or establishment, spirituality is not necessarily associated with any formal system. All of the above make the conceptualization of religiosity a difficult task and, as is clear, have created a diversity of conceptions within social science.
Taylor, Chatters and Levin (2004) argue that while religion, traditionally, has been considered to be the vehicle by which individuals can reach spirituality, there are some who advocate the detachment of religion and spirituality. They mention that some might not see religion as being essential for reaching spirituality and that some people take that idea further and valorize spirituality over religion. Religion, in their view, did not help human beings to reach spirituality and contentment. Koenig (2003), who advocates the use of the term ‘religion’ rather than ‘spirituality’ to cover all such ideas, suggests that spirituality is a modern term which became increasingly popular in the 1990s. Wulff (1997) argues that the term religion itself has been used ever since the fifth century; however, he says the term spirituality has gained more attention recently.
The current perception of spirituality as described by Geroge et al. (2000) has its historical origin in religions. The omission of ‘transcendence’ of entity and the endorsement of the self as a source of spirit are two of the main characteristics of this new strain of spirituality. George et al. (2000) argue that the term spirituality has increasingly been used independently from religion, or as a substitute for religion and religiosity. They also claim that the increase in the orientation towards spirituality is due to secularism and that hostile views towards religions have fostered the separation between spirituality and religion.
71 Some research suggests that spirituality as a concept invites multifaceted discussions and discourses in the mental health professions (Thoresen 1999; George et al. 2000). Spirituality, as Hall, French and Marteau (2003) indicate, is a new term which is almost considered by some to allude to a common humanistic experience with the aim of finding meaning of the’ ‘transcendence’. On the other hand, the subjects of the sanctified, the supernatural, and perceptions about divine influence on daily life are some components of both spirituality and religion (George et al. 2000; Koenig 1998; Hall, French and Marteau 2003). Hall, French and Marteau point out that the
concrete and individualized manifestations of ‘spiritualities’ tend to function not as universals but precisely the opposite: unique religions with only one member (2004 p. 1720).
As I have already indicated, some scholars advocate the use of the term religion rather than that of spirituality. Koenig, for example, points out that it is possible to define religion in terms of beliefs, behaviour and perception. Religion, as he says, is a more comprehensive term and generally includes notions of spirituality. In his Integrating Research on Spirituality and Health and Well-Being Into Service Delivery conference, Koeing (2003) describes spirituality as ‘diffuse’, difficult to measure and uniquely personal. He goes on to state that he employs ‘a broad definition of religion’ which means not ‘just going to church’ or participating in institutionalized religion. Religion, as Koenig describes it, ‘includes personal religious beliefs, personal commitment, practices, prayer, devotional reading, faith community involvement, attending services, practicing the rituals, group religious activities, volunteering for religious reasons’.
Hyman and Handal (2006 p. 269) explain that in religions such as Islam notions of spirituality do not exist as separate from religion. In their later research, in which they interviewed a number of religious professionals (Imams, Ministers, Priests and Rabbis), they note that the Islamic groups indicated that religion and spirituality mean exactly the same thing to Muslim people. Scholars such as Hill
72 (2000), Taylor, Chatters and Levin (2004), and Koeing, McCullough and Larson (2001) consider religion and spirituality to share many aspects. The latter scholars argue that the concepts share a ‘sacred core’ (Koenig McCullough and Larson. 2001 p. 7).
The distinction between spirituality and religion has been neatly summarized by Koenig, McCullough and Larson (2001 p. 8). They claim that religion is more community-focused, observable, measurable, objective, formal, organized and behaviourally oriented, is authoritarian in terms of behaviour, and has a set of guidelines separating good from evil. On the other hand, they claim spirituality is individualistic, less visible, less measurable, more subjective, less formal, less systematic, and more emotionally oriented. They assert that spirituality is not authoritarian, has less accountability, and is not doctrine-oriented.
Mental health professionals and religion
In the following section I address the gaps and challenges in relation to mental health and religion. The discussion will be placed within a historical context.
An early relationship
As Nolan (2000) suggests, understanding the historical characteristics of mental health is as important as understanding the conceptions of and approaches to mental health today. He asserts that in reflecting on history there is a need to acknowledge the complexity of the history of psychiatry, which has been strongly embedded in the social and political construct of society. Koenig (2003), Shafranske and Malony (1996), Spilka (1987), Bughra (2000) Kinzie (2000) deliberate at length on the importance of understanding the history of the mental health professions and how these incorporated an appreciation of religion. These scholars assert that the negative view of the mental health professions towards religion and its influence on mental health began a hundred years ago, and that
73 prior to this the relationship between religion and mental health was a more positive one – a point upon which all these scholars agree. The relationship between religion and the mental health professions has been described as going through various stages, and an overview of these is given below.
Bhugra (1996) suggests that historically there seemed to have been similarities among cultures in terms of the role of the religious person and the role of the healer in helping community members to deal with mental health problems. Combining both roles was not seen to be contradictory, regardless of the religious and cultural backgrounds, that is, whether Hindu, Greek, or Roman. Bhugra argues that in most cultures there were central beliefs that mental health problems were caused by possession by evil spirits, and that treatment included a combination of physical and religious rituals. This, he says, was also the case with medieval Muslim communities. Dols and Immisch (1992) suggest in their book, Majnun: the madman in medieval Islamic society, that in traditional societies a combination of medical, religious as well as familial support was used to treat a person with mental health problems. In his discussion of psychological support in medieval Islamic society, Al-Issa (2000d) confirms this point by observing how the understanding of psychological problems has historically been based on the Qur’an and the Hadith.
Koenig (2003) and Foskett (1996) expand on this point by explaining the strong historical connections between the Christian church and health. They observe that churches built hospitals and were instrumental in developing professions such as nursing and medicine, whose professionals were also seen as being Ministers. The first hospital for mental health problems was built in Jerusalem and was started by priests in the first century. Kinzie (2000) emphasizes the important influence of Judaism on the advancement of knowledge on psychological problems. Bhugra (1996) asserts that the connection between religions and psychological support continued up to the fifteenth century with both physicians and religious priests working together in the treatment process. However, he says that in the fifteenth century the church started to punish individuals who showed signs of mental health
74 problems, which were considered to be caused by demonic possession. Bates (1977), in an early piece of scholarship, suggested that the religious interpretation of the causes of mental health problems strengthened the position of the church in the medieval period, insofar as it gave the church power in dealing with such problems.
Bates (1977) suggests that the sixteenth century marked the introduction of the medical model to mental health issues. This classical medical model was, as she argues, a more humanistic and central approach to dealing with mental health problems. As this model became more influential and mental health problems came to be regarded as illness, the church became less important in dealing with such problems. Both Bhugra (1996) and Bates (1977) argue that one of the reasons for adopting the medical model was the emerging notion that disorders are organically, biochemically based, and that the aim of the medical doctor was thus to treat the pathological cause of the illness.
Foskett (1996) describes the influence of the church on the treatment of mental health problems, noting that until the eighteenth century a physician was not allowed to practice unless he had a licence from the church. He states that this changed in the eighteenth century when a priest needed permission from a physician to be allowed to work in a hospital. This medical approach became more influential in the nineteenth century as the number and range of scientific discoveries grew and incorporated medical understanding. The spread of secularization is also noted as contributing to the increased power of medicine over the church. Most scholars agree that there was, however, still an appreciation of the role of religion in the treatment of individuals with mental health problems up to the nineteenth century (Foskett 1996; Bates 1977; Koenig, McCullough, Larson 2001).
75 An emerging antipathy
Faiver, O'Brien, and Ingersoll (2000), Weaver et al. (1998) and Browning (1997) claim the negative orientation towards religion within the mental health profession had its origin in the anti-religious attitudes of twentieth-century writers such as Sigmund Freud. Faiver (2000) asserts that other scholars, such as B. F. Skinner and James Leuba, also adopted a strong position against religion. For scholars such as these, religion was considered to be a main contributor to psychological problems. Albert Ellis is another well-recognized scholar who adopted an aggressive attitude toward religion. Ellis (1986) saw religion as the source of all neuroses. He, like others, considered that guilt was central to most religious beliefs and it was significant in causing mental health problems. However these scholars, including Ellis (1986), went further by arguing that religious beliefs were constituted of irrational thinking, which consequently led to psychological problems.
Rhi (2001) and Browning (2003) state that Freud’s pioneering studies of the unconscious and his concept of religion as an infantile obsessive neurosis and as a behaviour of regression, while it helped people to cope with hopelessness in critical situations, radically exposed the shadowy aspects of the human soul, which had been carefully kept in the unconscious until the age of enlightment. They also claim that the counter argument about the primordial need of man for religion was almost simultaneously confirmed by Jung. Freud’s psychoanalytic concepts of religion have had a very significant influence on the psychiatry of North America (Rhi 2001; Browning 2003). These authors argue that this rejection of religion by a broad range of academic critics is seen in the work of Max Weber, William James, Clifford Geertz, Eric Erikson, Heinz Kohut and Anthony Wallace.
Richards and Bergin (2000a p.10) argue that the work of Sigmund Freud and Albert Ellis (among others) had a significant influence on all of the mental health professions. They suggest that as a result of their influence, the profession adopted a secular ‘naturalistic’, ‘mechanistic’, ‘hedonistic’, ‘relativistic’ ‘atheistic’
76 orientation arguably all of these conflict with the values of non-western societies. Fernando (2002) observes that this western scientific medical model has replaced traditional healing, in which there is no distinction between religious healing and medical treatment. He argues that the mental health medical model, which has developed in the West, is not influenced by the religion, ethics or spirituality of the culture in which the model itself is now being applied. This negative attitude towards religion has created competitive and tensional interaction between mental health professions and religion. Scholars such as Gallagher, Wadsworth and Stratton (2002), Fernando (2002), Tseng (2001) and Rhi (2001), amongst others, are critical of the western-based mental health professions and argue that professionals in the field are trained to apply a scientific approach when dealing with individuals with mental health problems, whether those individuals are from western or non-western backgrounds, and whether they have religious beliefs or are atheists. All of these writers are damning of the fact that mental health professionals apply the western approach whether they themselves have a religious or non-religious orientation.
Pargament (1997), Pieper (2005) and Koenig (2003) claim that as a result of the work of the seminal writers named earlier, most mental health professionals consider religion to be the cause of mental health problems, and do not pay attention to the possibility that individuals with mental health problems might seek refuge in religion as a helpful coping mechanism. These scholars note that there are seemingly common perceptions about the negative effect of religion on mental health in the western research, where religiosity is considered to be a coping mechanism for individuals lacking power and strength to cope with life. Loewenthl (1997) supports this point by noting the tendency among mental health professionals to consider the negative effect of religiosity on both how people understand their distress and the therapeutic process in which they are engaged. Dein (1997) and Richards (2000) note that this negative orientation towards religion has meant that the subject, of religion, until very recently, has had very limited attention in the mental health literature. This is interesting given the
77 reported significance of religion to many individuals. Ironically, associated subjects such ‘cultural sensitivity’, ‘race’ and ‘ethnicity’ have received much attention and appear to have been considered important elements in emerging debates amongst mental health professionals. As an example of the evident avoidance of religion, Weaver (1998) notes that, until recently, the Diagnostic and Statistical Manual of Mental Disorders avoided the subject of religion and spirituality altogether.
A number of authors suggest that a consequence of the lack of recognition of religious and spiritual elements within mental health services is that many individuals and communities avoid the mental health professions, due to its lack of sensitivity toward religion (Corbett 1999; Koenig 1990; Purdy, Simari, Colon 1983). Hartog and Gow (2005) argue that this failure to appreciate the influence of religion has had a large impact on religious communities as these communities have been enabled to foster stereotypical beliefs about health professionals, which in turn have influenced the uptake or non-uptake by their members of mental health services. Richards and Bergin (2000) and Koenig (2003) suggest that many religious individuals with psychological problems might consider the support of the profession as a last resort after having exhausted other resources such as family members and religious leaders. Other researchers such as Adler and George (1998), Lefley, Sandoval and Charles (1998), Mulatu (1999), Razali (2000) and Youssef (2006) indicate that many individuals with mental health problems prefer to access religious healers rather than seeking professional medical help. Results from research such as that conducted by Hartog and Gow (2005) emphasize that even when individuals from religious communities, such as Christians, access mental health services they prefer to seek the help of religious mental health professionals rather than the ‘secular’ ones (Hartog & Gow 2005). Levin (2001) makes the point by strongly noting the confusion individuals experience having to accept the fact that mental health professionals can deny something that may be so important to them.
78 The changing situation
Many scholars, such as Koenig (1998), Larson et al. (1998), Thoresen (1999), Gallagher, Wadsworth, and Stratton (2002), Canda and Furman (1999), Weaver et al. (1998), Hill et al. (1999), Idler and George (1998), and Shafranske and Malony (1996) indicate that the situation has changed and that religious beliefs are seen by many contemporary mental health professionals and writers as increasingly important. According to these writers there is no doubt that contemporary scholars and mental health professionals would find it hard to keep avoiding the subject of religion in relation to mental health problems and the coping process.
Miller and Thoresen (2003), Richards and Bergin (2000a) and Koenig (2003) suggest that the negative attitude that was adopted during most of the last century began to change in the 1990s, and that since then there has been an increase in attention to religion and spirituality in the mental health field. Zinnbauer et al. (1997) assert that these efforts have focused on understanding, exploring, and theorizing about concepts related to mental health and religion. Research in the area highlights the importance of religion in identifying various ‘existential’ problems (Dein 2000).
Littlewood & Lipsedge (1997) found that the emphasis on religious interpretations and healing has shown no sign of diminishing in traditional cultures. This fact, alongside the understanding that psychiatric treatment is not a familiar alternative in many societies in developing countries and traditional societies, suggests to them an emerging priority to acknowledge religious issues in mental health service delivery in developing countries. They argue that in non-western societies mental health problems are not commonly attributed to medical causes, and that in some of these societies there is no differentiation between physical and psychological problems. Both are treated with the same religious rituals. Thus a series of reports on non-western societies has rightly stressed the importance of considering cultural and religious issues when developing mental health programmes (Al-Issa 2000a;
79 Wig 1999; De Silva 2006). It is interesting to note that the renewed interest in religion and spirituality is not exclusive to traditional cultures. Scholars also observe an increased push within western societies to understand spirituality and religious beliefs in mental health services (Zinnbauer et al. 1997; Shafranske & Malony 1996; Gallagher, Wadsworth and Stratton 2002).
Many scholars note the benefit of incorporating and understanding religion in mental health problems (Larson et al. 1998; Pargament 1997; Barlow & Bergin 1998). These scholars assert that an appreciation of religious beliefs assists in understanding beliefs about the experience of distress, the attribution of mental health problems, as well as the promotion of mental health and coping with mental health problems. They acknowledge the benefit of religion in understanding the healing aspects and interventions religious individuals follow to help them to deal with distress.
Understanding the religious beliefs of individuals with mental health problems is seen by Littlewood (1997) as a way of understanding their explanatory model: that is, the way they understand and explain problems. An appreciation of an individual’s explanatory model is considered important in providing culturally sensitive care for individuals. The mission of religion is, scholars have noted, to inform us about the nature of being human, the strengths and weaknesses of humans, as well as the expected ways in which to deal with problems in order to gain and maintain healthy wellbeing. Pargament (1997), Kinzie (2000), Shafranske and Malony (1996), Loewnthal (1997), Dein (2000) and Gall et al. (2005) have noted the importance of religion as people turn to it as a coping mechanism during hard times. Al-Issa (2000a) and Pargament (1997) argue that people tend to be more religious during stressful, times, with the advancement of age, when most vulnerable and affected by loss, and when they are affected by health problems.
Some writers view this tendency to participate in religious activities and observe values as coping strategies (Al-Issa 2000a). Gopaul-McNicol (1997) and
80 Pargament (1997) note that individuals tend to become more directed toward religion when they are facing painful experiences, even though they may not have tended to do this in the same way in the past. They argue that often religious activities and groups seem to offer these individuals feelings of encouragement and connection (Gopaul-McNicol 1997). Gallagher, Wadsworth and Stratton (2002) observe that the significance of religion may be due to the psychological aspect of being human, and they make the point that this is also an important concern for mental health professionals. Religion is considered to enable better coping with mental health problems, in spite of the complexity of the relationship betweenthem. Larson (1998), Pargament (1997) and Richards and Bergin (2000a) consider that acknowledging religious beliefs in clinical interventions is important as it can contribute to building a trusting professional relationship, and, as importantly, can assist in incorporating a spiritual mechanism which may help people to cope better and to change more easily.
Some scholars, such as Levin and Chatters (1998), Pargament (1997) and Richards and Bergin (2000a), assert that the understanding of religious issues by mental health professionals is vital in gaining trust and acceptance not only at the level of the individuals with mental health problems, but also among religious leaders and community groups. The latter scholars consider the acknowledgment of religion is not only an important element in the recognition of the individuality and diversity of people accessing mental health services, but also increases the chances of individuals with mental health problems accessing mental health services. Exline (2002) and Koenig (2001) suggest that the increased evidence of interest in religion in the literature and among professionals is assisting mental health professionals to gain insight into the effect of religion on mental health – whether this is a positive or a negative effect.
Dein and Lipsedge (1998) and Koenig (2003) claim that these new developments are manifested in the large amount of research and the substantial number of studies in the field, as well as in the education and training of mental health
81 professionals. As Koenig (2003) noted at a conference focusing on religion and mental health, the increased significance of religion in relation to mental health is strongly evident in the establishment of specialized journals. These include Mental Health, Religion & Culture or International Journal for the Psychology of Religion, Journal of Spirituality in Mental Health. Koenig also noted that other ‘secular’ journals have dedicated some issues to the subject of religion and mental health.
Qualitative as well as quantitative research has been increasing in the area of spirituality and religion in relation to women, minorities, carers and coping problems. Miller and Thoresen (2003) note also that there has been an improvement in the quality of research in terms of methodology and in the variety of focus. Shafranske and Malony (1996) and Richards and Bergin (2000b) claim that it is becoming increasingly recognized that professionals need to be trained in aspects of religion in order to deliver quality services for clients in diverse societies and orientations.
Youssef (2006), Hyman (2006) and Weaver et al. (1998) note that mental health professionals are reported to be paying more attention to faith groups in order to promote health issues and to provide education to them. They observe that, in the late 1990s, there was also an increased tendency to interact and co-operate with religious leaders. Weaver et al. (1998) note that an example of this is the production of mental health education publications targeting spiritual leaders. Richards and Bergin (2000) argue that one of the main indications of the increased recognition of the importance of religion amongst mental health professions is the inclusion of religion in ethical guidelines for the professional organizations. Religion is considered to be an important cultural aspect which mental health professionals need to take into account when dealing with mental health problems. Gopaul-McNicol (1997) and Shafranske and Malony (1996), for example, note that DSM IV has recently started to recognize the importance of religious experiences amongst individuals with mental health problems. This is, they argue, a clear
82 indication of the growing importance of religious issues in working with people with mental health problems.
Challenges and opportunities
In spite of the evidence that there is an increased realization among mental health professionals of the ethical importance of considering religious issues, scholars also note that gaining adequate knowledge in the area is not easy as Richards and Bergin (2000b), Carr (2000), Kinzie (2000) and Weaver et al. (1998b) argue. These writers suggest that the plurality of beliefs and religions and the overlap of religions and spirituality make the consideration of religion within the clinical setting a most challenging and complicated task. Rhi (2001) asserts that religion continues to be a most debated subject within the mental health professions.
Whilst the increased interest in religion is seen to be positive by many scholars, there are many mental health professionals, such as Ellis (2006), who continue to warn against religion, and who continue to argue that it contributes to mental health problems. Gallagher, Wadsworth and Stratton (2002) suggest that many mental health professionals still avoid the subject of religion due to the sensitivity of the subject, despite the fact that there is, he says, an increased understanding that many individuals accessing mental health services subscribe to religious beliefs. This is a fact that, Thoresen (1999) explains, is due to the increased social, environmental, and political problems in the world today.
Carr (2000) considers that the plurality of religions around the world is confusing for mental health professionals. Other elements may contribute to making the task of addressing religion in mental health a challenging one. Pargament (1997) and Shafranske and Malony (1996) suggest that a key factor is the subjectivity of religious experience. Many religious experiences are private and symbolic, making them difficult to interpret in a uniform or consistent manner.
83 According to Weaver et al. (1998), another challenge is presented by the fact that not many mental health professionals identify themselves as religious. They suggest that this could be one of the reasons for the lack of detailed research on religion and spirituality in the mental health area. Studies have indicated that the number of mental health professionals who have religious beliefs is considerably fewer than the rest of the population. Shafranske and Malony (1996) posit a common underlying reason for mental health professionals excluding religion. They assert that this is due to their need to be free of bias, and religion is an element which might be seen to interfere with this goal. Richards and Bergin (2000b) and Shafranske and Maloney (1996) assert that what makes it even harder for mental health professionals is that they do not receive adequate training in the area of spirituality and religion.
What Richards and Bergin (2000b) anticipate is that the acknowledgement of the significance of religion will increase the chance of individuals with mental health problems accessing mental health services. Although they are firm in their assertion that it is important for mental health professions to acknowledge the significance of religion, they note that professionals do not need to be of the same religion or spiritual beliefs as the clients they are dealing with. They place their argument in an ethical framework, claiming that the need for understanding and acknowledgment of religious issues when dealing with individuals with psychological problems is part of an ethical commitment to clients. They add that in order to build a sound trusting relationship, mental health professionals need to acknowledge the religious orientation of clients from different cultures and nationalities.
The need to pay attention to religion is vital, as scholars such as Gopaul-McNicol (1997), Shafranske and Malony (1996), Pargament (1997) and Pieper (2005) note. They assert that the majority of people who need mental health services use religion as their coping strategy and identify themselves as religious. Pargament (1997) argues that religious studies can assist us in knowing more about religion.
84 In other words, they can expand our understanding of religion beliefs, practices, values and relationships. Koenig (1998) argues while there is a need for research in religion in relation to mental health in general there is growing need to explore religion in non-Christian societies because it has had far less attention in these countries.
Idler and George (1998), Puchalski, Larson, Lu (2000) and Russell (2004) suggest that mental health professionals need to recognize, appreciate, and value the point of view of individuals with mental health problems. They say that there is a need to employ strategies which are relevant to their clients’ belief systems. It is understandable that incorporating religion and spirituality into clinical practice is a difficult task, especially given the absence of accumulated experience and the lack of training in the area. Gallagher, Wadsworth and Stratton (2002) and McCullough and Larson (1998) also suggest that as well as obtaining a theoretical appreciation of the importance of religion in relation to mental health, practitioners need to be given the skills to apply this understanding in the clinical setting. Pargament (1997) asserts that religion needs to be considered within a familial, organizational and cultural context. Mental health professionals need to acknowledge each of these contexts and the variations they give rise to when dealing with individuals with mental health problems (Richards & Bergin 2000a).
Summary
In this chapter I have explained how historically religion was seen as an important component in the diagnosis and treatment of mental health problems. I have described some of the origins of the emerging negative views about religion and their effects on mental health thinking, and how these created considerable hostility towards religion among many mental health professionals. I have also given a brief summary of some of the literature which highlights the gaps that have been seen to be created in the practice of mental health as a result of negative attitudes towards religion. Finally, I have outlined some of the emerging positive attitudes toward
85 religion which are expressed by scholars who are calling for religion in mental health practice to be re-evaluated. In the next chapter I present the data from my research in which I outline how a cohort of Jordanian Muslim people with a mental health diagnosis incorporated otherwise religious elements in their understanding of their mental health problems.
86
CHAPTER FIVE
PARTICIPANTS’ PERCEPTIONS OF RELIGION AND RELIGIOSITY
In this chapter I reflect on discussions with the participants, all of whom were diagnosed with mental health problems and were interviewed in an outpatient clinic at the National Centre of Mental Health in Jordan. I discuss in particular their perception of religion and how they conceptualized their mental health problems. As Shafranske and Malony (1996 p. 568) explain:
what is of clinical significance may rest not so much on whether particular clients are religious or not nor in what congregation they affiliate, but rather ‘How are they religious’;
and, furthermore, they suggest a question of key importance is: ‘what part does religious involvement play in the client’s psychology?’ (Shafranske and Malony 1996 p. 569)
In this chapter I describe in particular how participants talked about their religious orientations in relation to their mental health problems. They reflected on meanings and levels of religiosity or non-religiosity. When participants talked about their mental health problems, they discussed them in relation to how their family and society conceptualized these problems. I found that family perceptions of mental health problems had an important effect on how participants shaped their own understanding of them.
In this first section, I present first the participants’ notions of religion and religiosity. I then highlight the issue of stigma that emerged and consider how the
87 stigma associated with mental health problems was seen to contribute to participants’ perceptions and definitions of their own psychological problems.
Perceptions of Religion
All participants referred to their religion when discussing the causation of their mental health problem or their approaches to help-seeking.
Male and female participants manifested their level of religiosity through their style of dress, and their language, for example by incorporating Qur’an scripts and prophetic sayings in their conversations. Some women wore modern clothes and did not cover their hair. Others were wearing modern clothing and covering their hair with a hijab (the head cover worn by some Muslim women). Some were wearing a black dress and covering their faces with a khimar (material to cover the face, as some Muslims believe is obligatory for women). Some male participants wore modern clothing while others had a beard which, in Muslim societies, indicates religiosity.
Being religious
Most male and female participants described themselves as religious and strong believers in Allah. Their various descriptions of being religious or spiritual were embedded in their conversations. For example, some mentioned they observed the ethics and principles of Islam rather than the everyday practices of their religion. Others indicated that the practice of religion, such as the fact that they prayed five times a day, was an indicator of their commitment to being religious.
Some considered their religion a blessing for which they thanked God. Amal was one of the young female participants who indicated a strong commitment to practicing religion saying:
88 I am religious. Thank God for the gift of believing in Him.
Mahmoud described how his commitment to his religion was deeply rooted and part of his history.
I have been religious, since my early young years.
Most male and female participants considered religion the main support for their day-to-day life, and for coping with difficulties. For them Islam was a way of life. This is something that is mentioned by most literature on Islam, such as the work by Horrie and Chippindale (2003). Ali, one of the young male participants, said:
I can’t imagine how I would be without my religious beliefs. Religion teaches us to deal with everything.
Baheera also reflected the same notion:
My beliefs are strong. I mean what else made me bear all that happened to me in the last 35 years except the belief in God.
When talking about religion, some talked about some of the features of their religiosity. Praying, going to mosques or watching religious TV channels were all indicators of religiosity among participants. Baheera talked passionately about her devotion to her religion and her spiritual connection with Allah. She described her religiosity in the following way:
I am religious, thank God. I am always reading the Qur’an and recalling prayers. I always mention Allah’s name. Thank God I am constantly praying. I also go to the mosque and listen to the speech by the Imam. I attend religion lessons. At home I always watch the religious channels.
Mahmoud said:
I am religious: I pray, and constantly read the Qur’an.
89 Nida, one of the female participants, said:
I believe in Allah and always distribute Sadaqa (charity money).
Maryam, one of the female participants, linked being religious to following Allah’s commands, being spiritual, and to having tolerance of mental health problems.
Thank Allah I am religious. I love to comply with what God wants us to do. I am accepting of my psychological problems.
Some compared their religiosity to others around them. Hannan, one of the female participants, who despite her wearing a Khimar, which usually suggests a strong commitment to religious beliefs, considered she was not religious enough, compared to her family members. The indication that she wanted to increase her religiosity was possibly related to the religious belief that the person needs to strive to improve the relationship with Allah, as mentioned in the Qur’an (Qur’an 6:135). Hannan told me:
To be honest I am moderate compared to them; I mean I am not little and not much religious. I mean all the female members of my family have been covering up their faces since a long time ago. I was the last one to wear Al- Khimar. I would like to be better. But I imagine I am okay. I am satisfied. Well, not exactly satisfied with my religiosity. I would like to be better.
On the other hand, Rania, one of the female participants, who was wearing modern western clothes and was not wearing a hijab, discussed her perceptions of religiosity by explaining that she was not fulfilling many of her duties as a Muslim, despite the fact that she was committed to being ethical, generous, and forgiving. She expressed her religiosity in relation to her behaviour with others and deep beliefs in Allah, despite not practicing many of her obligations as a Muslim. She reported:
I am a good Muslim with my manners and values, in spite of failing to practice some of the religious teachings.
90 She said she had found that she did not have enough strength to follow some of the practices. She felt that forcing the practice on herself made things difficult for her in terms of coping with her mental health problems. For example, she felt that wearing hijab did not help her overcome her depression. On the contrary, she felt her depression worsened when she wore a hijab. This was in spite of the encouragement and the support of her husband, daughters, and friends to continue wearing it as part of her duties. She explained the encouragement of her family in terms of them wanting to help her to strengthen her spiritually in order to deal with her psychological problems. Although she believed that wearing a hijab was part of her religious duty as a Muslim woman, she did not think that it was the only indication of being a good Muslim. Rania found difficulties in applying the practice of wearing hijab, and suggested that this led her to focus on other features of her religion that she found herself more capable of following.
I am still a good Muslim, in spite of not covering my head. I wore it for 20 days only. I thought I was ready for it. My husband and my daughters liked it but I felt more depressed. I stopped going to the salon to have my hair done. I consider myself to be religious as long as I am not hurting anyone.
Both male and female participants considered some of their religious practices to be based on following traditions rather than following the spirit of their religion. They noted that for some the purpose of following these traditions was to be accepted by others, and to maintain a good image in the community, but not to genuinely follow the religion. Salma, one of the young female participants, reflected on the differences in the concept of religiosity between her and others around her, by saying:
My family is old-fashioned, but not religious. They only follow traditions. They just like to show off. I believe practising religion is supposed to be with your own will, and genuinely from your heart. It is supposed to come from your own self and not to be imposed on you to please others around you or for the family to have a good image.
91 Some participants used a variety of definitions of religiosity. They defined religiosity differently to some commonly held perceptions among religious people. For example, some considered that dressing in a certain way, as suggested by some religious groups, was not a sign of religiosity. Burhan, one of the male participants who considered himself to be a practising Muslim, compared his perceptions of religiosity to others, saying:
I am not religious as some individuals assume religiosity to be. No. Look at me, I don’t have a long beard, and I am not wearing dishdasha (traditional dress worn by some male Muslims). Is that right? I am still religious. What I have is the knowledge about religion, which every Muslim needs to have about Islam.
He further explained that he did not agree with those who impose their opinion about religion on others, or claim superiority as they think they have more knowledge of the religion than others. In the following statement he reflected the Islamic religion’s central belief that there is no mediating power between human beings and God:
But this is religion and it is not exclusive for some people or a group. The religion is for everyone.
Some participants considered open-mindedness to be an important criterion in their perceptions about religiosity. They compared themselves to other individuals who considered themselves to be religious but who in many cases were not open to new experiences. They considered this was caused by a lack of a right understanding of Islamic religion. Religion was seen by these people as being not well understood by those individuals who consider themselves religious. Firas, one of the male participants considered the need to better understand the Qur’an. Khan (15.10.06) discusses a growing tendency among many Muslims who are calling for Ijtihad (which encourages exploring the Qur’an to move towards a more enlightened approach to life). Approaches which are applied by some Muslims are seen as backward-looking and not related to Islam. Firas reflected:
92 I mean I find it hard to find a common language with a very religious person. I mean I am an open-minded person in the area of religion. Religion does not make people narrow-minded or limited in the way they live. I mean there are so many things with some religious people which I do not believe in. They misunderstand the religion, not because the religion is wrong. They misinterpret the Qur’an.
He further explained that his open-mindedness was nurtured by being exposed to different cultural experiences in the West. For him, the encounter with different cultures pushed him into being open-minded and into valuing religion more:
I went through so many experiences in life. I learnt a lot by living in so many places. I lived in the era when Russia was communist. I witnessed a whole system deteriorating. The country was transferring to capitalism. I was in such a country. I went to Holland and I went to other countries where their system is between two systems. I saw people changing, the way they think changed. I saw people before and after. I saw people in the Far East and in the US and and in the West. I lived so many experiences. Others might not able to comprehend these sorts of experiences. The experiences helped me to understand religion.
Religiosity and mental health
Some of the participants talked about starting to practice religion after they had been affected by mental health problems. They explained that their commitment to the practice of religion commenced as a coping strategy to help them deal with mental health problems.
This is congruent with some of the literature which suggests that people tend to be more religious during times of stress and with the advancement of age, when they are likely to be more vulnerable and affected by loss and health problems. The tendency to such religious activities and values is viewed as a coping strategy (Al- Issa 2000c; Pargament 1997; Corbett 1999; Pieper 2005; Maltby & Day 2003).
Jameel, one of the highly educated male participants in his early fifties, talked about the commitment to the ethics and values of religion. In spite of his
93 commitment to the ethics of his religion, he felt the need to commit to other aspects of religious practice after being affected with psychological problems.
I consider myself to be a believer all my life, but I didn’t used to practice everything. I didn’t used to pray and I didn’t go for pilgrimage. Of course, I didn’t commit sins, and I always liked to help others,. However, I only started praying and thinking about going to Meccaa two months ago. But I think that faith is a very important issue in life, and it might help in coping with difficult problems.
Whilst the practice of religion was seen by many as a way of coping, Muhseen, one of the male participants, told me that the strict practice of religion did not help in his case. He strictly practised his religion at the start of his disorder, because of the unpleasant intensity of the mental health problem. He said that this sudden extreme practicing of his religion delayed him in accessing professional help. He added that turning intensely to religion caused him more anxiety, and made him feel more guilty about past possible wrongdoings. He thought that he was to blame for the problems he was suffering, because of sins he had committed. He felt that the sudden onset of mental health problems made him vulnerable to what he considered later on to be wrong religious messages. These messages, he said, were from some Sheikhs who discouraged people from considering themselves as having a mental health problem and encouraged them to disregard professional medical help.
I became very religious at the start of my illness. I stopped listening to any music. I was only listening to religious tapes. These religious tapes caused me more anxiety. I mean every young guy makes some mistakes, you know. Listening to these religious tapes reminded me of everything I did. I think I over-reacted. I now advise anyone with an illness similar to the one I have not to listen to these sorts of things, because being in such a case you wouldn’t be stable, and your mind wouldn’t function well. You would have lots of memories about the past and then you would have more anxiety.
94 Loss of Religiosity
Whilst most research on religion has suggested that there is a strong return to religious practice in times of crisis (Pargament 1997; Taylor et al. 2004; Chen & Koenig 2006), this study suggests that some male and female participants tended to practice their religion less after being affected with psychological problems. Some said that they did not follow the Islamic tradition as much as they did before being psychologically affected. Some said they had stopped daily practices of religion since becoming unwell. However, stopping some of their religious practices also led to many of them feeling guilty and confused.
When participants described themselves as not being religious, they generally meant that they failed to perform some practices such as praying or fasting or wearing a hijab (for women), rather than that they did not endorse their religious beliefs. Participants generally described themselves as being religious if they performed daily religious practice, or sometime if they participated in extra voluntarily religious activities. Participants described themselves as being not religious if they did not pray five times a day or if they did not read the Qur’an regularly, even if they still believed in the philosophy of Islam. In other words, when participants described themselves as being not religious, the evidence they gave for this was that they were not praying or not reading the Qur’an.
Being away from religion was associated with feelings of guilt for some of the participants. Shakeera, one of the female participants, described herself as not being religious enough because she had not been practising some of the required daily worship after being affected with depression:
Honestly, I am not religious as much as I want to be. I used to pray. I don’t any more. It is because of the illness.
Nida also emphasized this point by saying:
95 When the disorder is intense, I pray less. I can’t concentrate on praying. I try, but I can’t.
The doubts and hesitation about religious issues were discussed more by male than by female participants, although all participants talked about either being religious or not religious. Three of the male participants presented different levels of uncertainty with regards to their religious beliefs.
Muhseen described himself as not religious. In his opinion this was due to negative experiences with religion which he had at the start of his mental health problems. He indicated earlier in the interview that he strictly practised religion at the start of his problems and reported that he reacted later on by not being able to practice religion. He expressed the feeling of being guilty thus:
I was religious for some time but I am not any more. I feel so sorry about that, I am not even praying any more. At the start of the psychological problem I was so religious. I stopped working. I was only praying and reading the Qur’an. It was so hard at the start. I feel I can’t pray now.
He further reflected on another aspect which was related to his basic religious beliefs, and how his mental health problems affected his thinking about religion and social values.
This sort of illness makes you question many things in your life. Your thinking becomes deeper. You question everything. You watch people walking and think about how they were created. Who created them? Why? It is a bad illness.
Alwan, a male participant diagnosed with obsessive compulsive disorder, also disclosed a deeper level of uncertainty in relation to how mental health problems affected his religious beliefs. He told me how he started to have doubts about his beliefs, although he kept these obsessive thoughts confidential because he felt guilty and worried that these doubts about religion might not be accepted by family members or friends. He reported hesitantly:
96 I don’t know. I think the degrees of faith are different from one person to another. I mean I have these feelings now. (Low voice) I don’t know. It is hard; it is hard for me to talk about it. It is just that I have a problem now in believing in … so many things … I don’t know. I mean I have doubts in the presence of God and the judgment day and all these sort of things. I would start to doubt these things to the extent where I am saying to myself ‘there is no benefit of my praying’, although I don’t like to talk about that. I find it hard deep inside to talk about these things.
Alwan discussed further how the existence of injustice in the world reinforced his doubts about the presence of God:
But the things around me confirm my ideas and convince me even more. I mean I haven’t seen any good things. There is no justice in life. The person would be saying if there is a God there is supposed to be justice in life.
He discussed his feelings of guilt and thoughts with a Sheikh in order to find relief and possible answers to his questions. However, in spite of his belief in the competency of the Sheikh; he still did not feel that his questions had been answered. He felt that there was a gap between his former religious persona and this new doubtful restless self which had been created by the disorder:
I discussed that with the mosque’s Imam and he explained so many things with clear Qur’anic scripts. He brought up some of the Prophet’s sayings about the presence of God. He discussed all these sort of issues. He is a competent one, but still I have these doubts.
Hussain suggested different levels of uncertainty about religious beliefs as he stated that he was almost a non-believer. He also said that even though he was affected with a mental health problem it did not change his orientation and attitude:
To be honest, I am almost an atheist. I don’t believe in God. It is has always been the case.
97 Summary
Most participants, male or female, said that they believed in God, and that they were practising Muslims. However, they had very differing views about what religiosity meant to them in practice. Most who talked about not practising their religion expressed feelings of guilt about this. Others saw the need to connect spiritually and ethically to their religion as more important than the actual practices of religion.
Perceptions of Mental Health Problems
Most male and female participants discussed their mental health problems in relation to how different religious, social, and medical aspects influenced their perceptions of these problems. Some recognized the presence of the psychological problems; others manifested uncertainty about them. Many of the participants who considered the problem to be a psychological one considered that this did not contradict their religious beliefs. The definition of the problem as a psychological one also relates to the problem being stigmatized in society, as will be discussed in more detail later in this chapter. .
The diagnosis
Most participants named their problem as a psychosocial one. Some used the same terms used by psychiatrists and other mental health professionals in the clinic to describe their disorders. One of these participants, Nour, reported:
I agree with the psychiatrist and his diagnosis. I am suffering from (in English) ‘depression’.
Burhan, one of the male participants, said:
98 I am suffering from anxiety. That’s what the psychiatrist said.
Others participants were not quite sure about the diagnosis and the naming of it. They believed that the diagnosis of the mental health professionals did not represent the whole story.
Some did not accept their disorder as being psychological, in spite of their receiving treatment at a psychiatric clinic. Some did not ask the psychiatrist about their diagnosis, perhaps because they had their own interpretation, which meant that the opinion of the psychiatrist was not important to them. Rather, these participants said that they expected the psychiatrist to provide them with medication for a problem which could be related to anxiety, frustration, tiredness, depression, anger, physical problems, or relationship problems. In some cases participants considered the problem to be a physical one.
For Amal, an educated young female participant who identified herself as religious, the way the psychiatrists and mental health professionals named her psychological problem did not matter. She reflected:
Maybe it is a bit of anxiety. And this is affecting me. I don’t know what the diagnosis is. I never asked. Maybe they told me but I didn’t pay attention. Maybe also because I am not convinced this is the mental health diagnosis. I came here because I want to get help. I am convinced that I do not have any problem, I do have a bit of a temper and it could be treated with some medication.
In spite of the diagnosis by a psychiatrist some participants did not consider their problem to be psychological, and explained it as due to difficult life events. Rania, one of the female participants, used the word ihbat (which means frustration) to describe her symptoms. This term was one of the most-used by the female and male participants to describe their mental health problems. Rania stated:
99 I don’t think it is a problem of depression, I think it is circumstances. What I have is ihbat (frustration). That’s all.
She further clarified her position by saying:
I don’t know. I went to Vienna for a holiday and I told my husband then that I do not think there is such thing as a person with mental illness. The life around us is the real illness for individuals. I was so happy to the extent where I used to forget I have a psychological problem and I even didn’t take medication at night. I was very happy.
Some were defensive about their psychiatric diagnosis, and provided a definition that this problem was not a psychological one. As he was commenting on the initial diagnosis of the psychiatrist, Hussain explained:
It is not phobia as the psychiatrist said. No, it is not phobia. It is nothing, nothing. It is just that I am a sort of a person who lives day by day. I don’t think of the future. I mean, I am not afraid of anyone. It is not that I am a troublemaker, I don’t get into trouble with people. It is not that I get into trouble like bad people do. You see.
Nida, a highly educated female participant, explained that she did not have the psychological problem of depression or anxiety as identified by the psychiatrist. She defined it differently, in spite of agreeing to take the prescribed medication and visiting the clinic.
It is not that I have a psychological problem, I only have a temper because of the difficulties I am experiencing in life.
Some participants thought that by not defining the problem as a mental health problem they would be able to cope with it better. Mahmoud, one of the male participants, reflected:
I try to convince myself that I am not ill. I try to ignore its presence. I try not to think that it is there. If I keep thinking that I have a psychological problem I would then feel it is controlling me.
100 Most male and female participants presented their problem as a physical one. Even those who described it as psychological, still partly considered the problem to be physical. Somatization or the presentation of psychological symptoms as physical complaints is well-documented among research in non-western societies in Kirmayer, Dao, Smith (1998), Razali & Hasanah (1999), Van Moffaert (1998), Bass Christopher (1990), Helman (2000). Budman (1992) and El-Islam (1998) argue that the presentation of physical symptoms is usually considered more acceptable within these cultures.
Somatization of psychological symptoms is viewed as a significant element in developing countries. It has been found in Saudi Arabia, India, Iraq, West Africa, Sudan, the Philippines.(Kleinman & Good 1985), Jordan (Al-Krenawi, Graham, Kandah 2000), Algeria (Al-Issa 2000b), Pakistan (Mubbashar 2000), Egypt (Okasha 1999) Dubai (Sulaiman et al. 2001), Kuwait and Qatar (El-Islam 2000). Psychologiazation, as Al-Issa (1995) suggest is not a familiar expression in most traditional societies. Somatization, on the other hand, is more understandable. The reason behind the tendency towards somatization is not the lack of vocabulary – as the Arabic language, for example is rich in suitable expressions – but other social and cultural factors.
When they first experienced mental health problems, a number of participants said that they considered their problem to be physical and accessed health services to find treatment for what they considered to be a physical illness. This concurs with research of scholars such as Kirmayer and Young (1998), who suggest that many individuals from non-western cultural backgrounds are not familiar with a healthcare system which is mostly associated with severe mental health disorders. They argue that many people from non-western countries use primary health services to get treatment for physical rather than for psychological problems..
Jameel, one of the male participants, reported:
101 I delayed the treatment of my condition. At the start I didn’t expect the problem to be psychological one. I went from one GP to another in order to treat the problem. After a while I realized it is a psychological problem. I didn’t know what exactly was happening to me.
Maryam, one of the female participants, presented the following physical problem to describe her depression: tightness in the chest.
My problem is tightness in the chest. I now also have a problem with my wisdom tooth. I was told by family this might be the reason for the headache. Every thing is mixed up. Thank God, what could I have done. I can do nothing, it is all in God’s hand.
This is reported, as El-Islam (1998) has indicated, to be a common physical symptom among both males and females in some Arabic communities.
Fouad, one of the male participants, talked about the difficulty of differentiating betwen the psychological and the physical. He defined his depression symptoms to be a mixture of physical and psychological problems. As Ansari (2002) explains, this idea might have its roots in the Islamic notion of the human being as a blend of three dimensions: body, mind, and spirit. These three aspects are believed to influence each other in the making of the complete personality of a human being.
Fouad stated:
At the end there is no line between the physical side and the human side of the human being. Practically at the end everything is interrelated or motkaml.
Some participants talked about their confusion and the journey they went through before reaching the decision that they had a psychological problem. Baheera, one of the female participants, told me:
I went to so many doctors for treatment, I told them: ‘I feel my body is shaking, my heart is beating fast, my mouth is dry’. Then I went to the private
102 hospital and told the female doctor about my problem and she said this is not a physical problem. She said it is stress- and fatigue-related.
Confusion
In spite of having accessed mental health services for some time, some of the participants remained confused about how to describe their problem. They still did not consider the problem to be psychological.
Mahmoud, one of the male participants, reported:
In my opinion, I think it is a mental health problem. Sometimes I suspect … I suspect it is not, maybe something else. I don’t know.
The word junun was used by a number of participants to describe their psychological problem. This is a term which is used for individuals with psychotic illnesses which in some cases require admission to hospitals. According to Al-Issa (2000a) junun may also mean not behaving according to social norms. Thus describing their condition as junun was based on the general perceptions of those around them. Suad, one of the female participants, said:
I don’t know. People say it is a junun (madness). I mean I think it is right; it is a madness illness (laughing jokingly).
Hussain, one of the male participants, said:
I think that there is no treatment for my problem. I mean I know myself, I don’t have a problem. Everyone knows exactly what is inside their heart. But I came here because my friend insisted I come here.
Media as a source of information
Most of the participants seemed to get their information about mental health problems from the media, especially television. They stated that the information
103 they got assisted them in identifying their problem as a psychological one. Sami, one of the males, reflected on how he knew about the possibility of being affected by a mental health problem after watching a program on TV:
I suspect that my problem is anxiety, because I heard from a TV show a description of similar symptoms to the ones I feel. I knew there was a problem with me. I knew I was sick.
Watching the educational programmes helped these participants to identify that psychological problems can affect individuals regardless of their level of religiosity.
Hannan, a female participant, who identified herself as highly religious, told of a story she watched on television. The story was about a religious scholar who was affected by a mental health problem. She said that watching that program helped her to define her problem as being a psychological one. Hannan said:
I have an illness. I watched a TV program on religious education; Muslim scholars talking about psychological problems. They said that psychological problems are illnesses. The sickness could affect people who are strong believers and religious too. I mean there is a famous, famous writer. He is a Muslim scholar. This person is sick with a mental illness. I mean there is such thing as a psychological problem. After watching this program, I recognized that I am suffering from a mental illness
Being affected with a mental health problem is not an indication that a person is not religious. The believer is also exposed to stresses and to psychological problems. This idea is also discussed by Muslim writers such as Yarkindi (2000).
Family, Society, and Stigma
Familial and societal perceptions in relation to mental health problems were considered to be important influences on the perceptions of participants with regard to their own mental health problems. For example, if family members considered
104 the problem a mental health one, this encouraged the participants to consider the problem a psychological disorder, and to seek treatment for it. On the other hand, if family members did not think the participant was suffering from a mental health problem, they were less likely to seek help and talked about feeling confused.
Hussain talked about his experience when he informed his family that he was going to access a mental health clinic. His family did not take the matter seriously as they did not perceive the problem to be a psychological one:
I told my mother about my coming here and she started to laugh. They know that I have no problem except when I am very angry, but I am not ill or have junun.
Shakeera, one of the female participants, explained how her mother’s view of her problems affected her own perceptions and created doubts about her mental health problems:
My mother says there is no such thing as a mental illness. She says ‘You are making your self crazy. You do not have any problem’. Sometimes I think about what she says and I say to myself, ‘It is true we are sort of crying without being hit’. These thoughts come to me especially when I am feeling better. It is like crying without being hit.
Some participants said their families found it easier to understand physical rather than psychological problems. Fouad said:
My mother is an old lady and she doesn’t comprehend psychological illness; she would understand the physical illness, for example if my legs or back hurt, I mean mental illness is a sort of an illness, even psychiatrists do feel puzzled sometimes with it. Right?
Many participants talked about society’s perception of their mental health problems and its effect on their own perception of their problems. The majority of participants talked about the stigmatization of psychological problems within society. This issue of stigma is reported in much research in Arabic and Muslim
105 societies. The literature indicates that there is stigma associated with emotional problems in Dubai (Sulaiman, Bhugra & De Silva 2001), Algeria (Al-Issa 2000b), and Jordan (Al-Krenawi, Graham, Kandah 2000). This is even though it has also been reported that there is no such stigma associated with mental health problems within the Islamic religion, as Dols and Immisch (1992) have indicated. In their book Majnun: the madman in medieval Islamic society, these authors assert that mental health problems are not stigmatized within Islam as a religion.
Muhseen, a male participant, reflected on what he saw as the stigma associated with mental health problems in society:
The society doesn’t accept this thing. They consider the person who visits a psychiatric clinic as not a normal human being. I consider this illness to be normal. Like a cold or any other ordinary illness, but it has a more specific nature. Any individual could be affected by this illness. Whether he was ordinary, poor, or rich, no matter who the person is.
Hannan, one of the female participants, talked about how people perceive individuals with mental health problems:
People call the person with psychological problems crazy.
The effects of stigma do not just attach to the person who is getting help, but extend to the whole family. Amal, one of the young female participants revealed how her family angrily reacted when she initially discussed her needs to gett help from a psychiatric clinic. The reaction of the family was because of their fear of being stigmatized by society. Amal said:
My family didn’t accept the idea. My father almost hit me when I told him. He said are you crazy do you want us to have bad reputation.
To deal with the stigma of mental health problems most participants stressed the importance of keeping the problem confidential. Suad, one of the female
106 participants confirmed how she kept her psychological problem confidential for fear of being stigmatized by people around her:
Of course, I wouldn’t tell anyone about my psychological problem. How can I tell people I have a psychological problem? I can’t. It is like telling people I am crazy. How do you expect people to understand? They would say; ‘she goes to a mental health clinic. She has something wrong with her’. Of course if there wasn’t something wrong with me I wouldn’t come here. Would I? (Laughing)
Many kept their mental health problems confidential, did not not even share them with close family members. Others disclosed their problem to close family relatives or close friends, but not to extended family members or friends.
While some literature asserts that ‘privacy’ within the Arabic Muslim family is ‘non-existent’ (Al-Krenawi & Graham 2003), it was apparent in my research that male and female participants tended to keep their mental health problems secret from their extended family and in some cases from their immediate family too. Many expressed the fear that, if others around them knew of their mental health problems, it might expose them to stereotyping even by their own family. They believed that psychological problems are stigmatized and that there are lot of misconceptions related to them.
Ali, one of the young male participants, reflected:
My relatives do not know that I am getting treatment in a psychiatric clinic; they still think I am the same person I used to be. Every one still thinks that I am going to graduate soon.
Similarly, Mahmoud, commented:
My immediate family are aware of the problem. But I don’t like anyone from my extended family to know about it. I mean like my grandmother and the other relatives. There is no need for them to know. People would interpret it differently. You can’t trust people, they are judgmental
107 Muhseen told me how he tried to hide his mental health problems by not showing any signs of them when communicating with others around him:
I will tell you having a mental health problem is a bit embarrassing, but as long as you communicate with people normally, and pretend you are happy and OK then there will be no problem.
Muhseen further discussed how he kept the problem confidential by avoiding mixing with people:
When I was under the influence of the illness I totally avoided the world. I isolated myself, not letting anyone know about my case. I didn’t let anyone notice any change in my behaviour or any sign of depression or anxiety. Soon after I was treated I got out of my isolation again as if there was no problem whatsoever.
To keep the problem confidential, and to deal with stigma, many female and male participants presented the problem to others as a physical rather than a psychological one. Hannan, one of the female participants, told me that she made sure that her mother-in-law did not know about her disorder for fear of being stigmatized and not respected enough by her husband’s family, which would undermine her position in the family:
I know it is a normal disorder, but I do not like anyone to know about it. I mean there are some in particular whom I do not want to know. I mean my mother-in-law. I didn’t tell her that I came to get treated here. She wouldn’t understand. I only told her that I want to get treatment for pain in my hand and head.
Fouad, one of the male participants talked about how he shared that he has a health problem with others, but he would present the problem as a physical one rather than a psychological one.
Friends and lecturers at uni do know about the problem. I do not however explain it as a mental illness problem. I presented as a physical problem.
108 Being cautious about keeping the problem confidential even extended to the clinical settings. Alwan, one male participant, discussed how he, indirectly, gathered information about his problem from professionals such as doctors, psychologists, nurses, and social workers. He did this by visiting general clinics or talking to people who visited the shop where he worked as a barber:
Of course I was careful so no one would know about my problem. I mean I was very careful to hide it. I might, for example, ask a doctor without touching on the subject directly. I would usually pretend that I am asking about someone else. I would say, for example it is about my cousin. So I would keep the attention away from my problem. I would then be able to discuss so many things with him.
Burhan, one of the male participants, observed how individuals responded to the diagnosis of their GPs if they suspected they had a mental health problem which needed to be treated.
If your doctor recommends you see a psychiatrist you would feel offended and you might even stop visiting that doctor. You would think that the doctor was accusing you of being crazy.
The perceived stigma associated with having a mental health problem delayed many from accessing help. Ng (1997) suggests that mental health services in some developing countries are stigmatized and therefore not adequately accessed. Accessing the psychiatric services is usually the last resort, as Alwan commented:
Honestly I thought of visiting a psychiatrist long ago. But I always felt embarrassed. The majority of people do not accept the idea of mental health problems. You know how it is. I come across so many different people, in my 12 years, and I met so many people who I think they have mental illness. Some have problems and they need to be treated. They might not even consider getting help because of fear of not being accepted among people around them.
In order to avoid being stigmatized some used a clinic far away from their home. Fouad explained his reason for choosing to avoid the clinic which was close to his home city and travelling for an hour to another clinic:
109 In the nearby hospital people know from my family name that I am a relative to such and such. I have a cousin there who works in the hospital and I do not want him to know that I’ve got this stuff. You know people’s culture, especially in the psychological issues, it is a bad culture. I do not want them to say that ‘Fouad went to the hospital and he is mentally ill’ or ‘He has a bit of madness’. This ultimately will reflect on me. For example marriage wise, relationships with people in general. People will question my mental condition.
Disclosing issues related to mental health problems was seen by some participants as threatening their role within the society. Alwan, one of the male participants, said:
My family knows about my psychological problems, but I do not tell them everything. If I tell them everything they then might doubt me. They would look at me as if I am a different person. I might not be well respected among them.
Male participants expressed concern about their eligibility for marriage. They felt their mental health problem might minimize their opportunities in getting married. As Muhseen explained:
I am accepting of my situation. But I mean I am not married yet. I am worried that no girl will agree to marry me if she or her family knows about my psychological problem.
There was a tendency among most male and female participants to consider their psychological problem less intense when compared to individuals with psychotic illnesses. In suggesting this they claimed that their mental health problems were then supposedly less stigmatized. Society, however, in their opinion, considers all psychological problems to be the same. As a consequences all mental health problems are stigmatized:
It is common knowledge that psychiatry is for crazy people. There is no understanding that psychological problems vary and there are some people who suffer from depression and it is a different sort of illness than schizophrenia for example. Anyone who accesses psychiatry is considered crazy. They do not consider that some psychological problems are a result of
110 pressure in life. Every psychological problem for people is the same. Everything is measured with the same criteria.
Jameel , another male participant, said:
There is psychosis and there is neurosis, but for most people mental illness means being nuts.
Burhan, one of the male participants, said that his mental health problem was not stigmatized as he did not act in aggressive ways. He thought that acting aggressively or violently would have been considered by those around him as an indication of being mad:
People around me know that I come here because I am crazy. (Laughing) Let me tell you I don’t look crazy. I do not look like I suffer from a mental illness. I am patient with others. I do not smack my children.
Ng (1997) and Fabrega (1991) argue that stigma is mainly associated with severe mental illnesses, which are characterized by frequent relapses and chronic characteristics A comparison between non-western societies and western societies in terms of their response to mental health problems was frequently mentioned by male and female, participants regardless of their level of religiosity or religious practice. Participants generally observed that western societies were considered to be more advanced in dealing with psychological issues. Psychological problems were considered to be more accepted and less stigmatized.
Hanan reported a cultural comparison of the interpretation of psychological disorders in this way:
Not many in our society are informed about psychological problems. They would think that the person with the psychiatric problem is crazy. They do not understand the real picture of the psychological problem, and that the person could be cured and not mad. People in our society do not understand. They are not sophisticated. If you were in a western country and you wanted to talk about your problem you would do so without any hesitation. You wouldn’t
111 feel afraid. On the contrary you might feel proud that you went to get help for your problems. You would find someone who would listen to you if you talked about it. That’s what I mean. I mean in our society it is different. We are not that advanced.
Likewise, Burhan, said:
I don’t want anyone to know about my problem. I don’t accept anyone talking about me and interpreting what I say the way it suits him. This is how we are. This is how our society is. We are not like Europe or other western countries. I mean western countries have their own laws, which they could follow. In our society we do not follow rules. So when I want to talk about my problems everyone will interpret it to suit themselves.
Forces reducing stigmatization
Some participants said that their family supported them in getting treatment. This seemed to reduce the experience of being stigmatized. Nida said:
My family encouraged me to see a psychiatrist. They told me go to a doctor and get medication to reduce the nervousness and the frustration I have, they are supportive of me coming to here and they do not mind.
Muhseen also talked about the support he got from his family, saying:
My sisters and brothers encouraged me to come here and they told me that it is an illness and it could be treated.
While the majority of participants believed that mental health problems were stigmatized, a small number said that although they were aware of the stigma attached to mental health problems they were not affected by this.
Sami said that knowledge about mental health problems helped him to overcome the social stigma attached to them:
112 There is no doubt that psychological problems are stigmatized in our society. But look at me; now I dare to come over here. But before, I used to feel embarrassed. I used to say to myself , ‘What if someone sees me, they would think that I am crazy’. But I changed once I learned about psychological problems, and that they are like any other physical illness.
While the majority of participants talked about stigma associated with mental health problems, there were some male and female participants who observed that there was an increased awareness in society. This was seen as a positive development. Some believed this to be due to an increase in educational programs on satellite TV and an increase in religious education, which they thought normalized mental health problems.
Baheera, one of the female participants, told her story of starting to get help for her mental health problem. A friend of her husband who had accessed the clinic encouraged her to do this. The person acknowledged the stigma, but explained that going to the clinic could lead to improvement.
Someone told my husband about the clinic. He told him there is a clinic, but people do not like to go to it because of fear of being considered crazy. He told him it is an illness like any other illness. It could be also caused by hormones and something like that.
Sami explained how he reached the point where he was not affected by the stigma associated with the problems. He reported:
There are many people who are afraid to access the service here because they are worried that people might talk about them, call them crazy, or accuse them of being cursed by the devil or some sort of thing. You could find people like that. For me I have self-confidence, thank God. I don’t care at all about what people could say. It doesn’t affect me.
For some, the sharing of a mental health problem provided an opportunity to encourage others to seek help. Sami further reported:
113 Many of my relatives and friends know about me having a mental health problem. I told them, ‘It is normal’. I am not ashamed of something like that. As long as I benefited out of it, I like to benefit others. I advised so many to get psychiatric help if they have problems. Some would say sometimes that they go to sheikhs; I usually tell them that I had been to a sheikh and I didn’t feel better, and I felt much better when I started psychiatric treatment. I tell them, ‘I could take you if you like’.
Nida, one of the female participants, reflected on how the situation was changing and how many were becoming more aware of psychological problems:
People do now accept psychiatry a bit better. People have changed from what they used to be. They are more educated and informed. But there are some people who do not accept psychiatry.
Summary
In this chapter, I have presented the main themes which emerged from the discussions with participants about their perceptions of their religiosity and its relationship to their mental health problems. Participants discussed different levels of religiosity when they talked about religion in relation to their psychological problems. In the next three chapters, I will analyse how participants perceived the cause of those problems and relate this to the writings about mental health in the two core Islamic texts of the Qur’an and the Hadith.
114 CHAPTER SIX
ATTRIBUTING CAUSATION OF MENTAL HEALTH PROBLEMS
Introduction
The three sections in this chapter address how the causation of mental health problems is attributed. In these sections I reflect on how participants conceptualized the causes of their mental health problems and I also analyse how the Qur’an and the prophetic traditions interpret the conceptualization of such problems.
A large number of scholars have attested to the fact that individuals vary in their perceptions of the causations of all problems, including mental health problems. They argue that these variations are related to cultural background and religious and/or spiritual beliefs (Williams & Healy 2001; Helman 2000; Kirmayer et al. 1994; Al-Krenawi 1999a; Lawrence et al. 2006; Srinivasan & Thara 2001; Ayalon 2002; Cirakoglu et al. 2003; Luk & Bond 1992; Hartog & Gow 2005). Edman and Koon (2000) argue that the attribution of mental health problems also varies with age and level of education. Williams and Healy (2001) consider the search for identity to be an underlying driver, which prompts all individuals to attribute their experience of suffering to some cause. Kirmayer et al. (2004), Ayalon and Young (2005), Halter (2003), and Robbins (1994) argue that how the causation of mental health problems is attributed influences the way symptoms are presented, the help- seeking process that people engage in, and the success or otherwise of the interventions that are used to help them.
115 Al-Krenawi (1999) asserts that in order to deal effectively with mental health problems it is vital to be aware of the attributions individuals with mental health problems adopt in order to help them to deal with their distress. This, he suggests, is especially important cross-culturally as individuals tend to symbolize their illness and problematic experiences differently. Helman (2000) argues that theories about the cause of mental health problems are emergent in the inherited cultural and folklorist tradition of any society. These theories, he explains, provide logical cultural interpretations for disturbances, even though they do not have any proven scientific validity. The significant function of these theories is to provide individuals with some form of logical clarification of their experiences of illnesses and their suffering. The theories originate within the culture and are influenced by various other social and cultural elements. Spilka and McIntosh (1995), Hartog and Gow (2005), Sheikh and Furnham (2000), and Edman and Koon (2000) argue that religion as well as culture is significant in the discussion about attributing the causations of mental health problems.
Most scholars agree that the causes of mental health problems can be attributed by people to one or several different interacting events (Helman 1994; Ross & Sastry 1999; Hall, French and Marteau 2003). The latter scholars argue that there are extensive conflicting views in the literature about how people attribute causation to their problems. Most scholars classify the causation of mental health problems as either internal elements, such as attributing the problems to an individual’s own action, or as external forces such as social causations. Murdock, Wilson and Frederick (1980) posit two attributional categories for mental health problems across societies and cultures: The first category is natural attribution, which includes stress, trauma, organic problems, and in some ethnic communities problems with internal somatic events such as cold or hot blood. The second category is that which the authors suggest is adopted by many communities – psychological and social attributions.
116 Robbins and Kirmayer (1991) classify three categories for attribution of symptoms: psychological, somatic, and normalizing. Helman (2000) goes further, arguing that there are four main causal attributions for the aetiology of illness. These are: 1. Individual attribution (which is common in industrialized societies), when an individual is considered responsible for personal suffering and ill behaviour. This attribution generates feelings of guilt and stigmatisation for being ill. 2. The natural world: and the affect of the climate and the environment on the cause of illness. 3. The social world: The most common features are witchcraft, sorcery and the ‘evil eye’. These sort of attributions are more common in non-industrialized traditional societies. They are also more dominant when a society is undergoing transition and social change, social problems, crises, and uncertainty. In industrialized societies stress plays a major factor in attribution of illness. The cause of the stress could be attributed to a spouse, children, work, or relationships. 4. The supernatural world: The illness is attributed here to God, ancestor spirits, and/or punishment for wrongdoing or for sin.
According to Helman (2000), Sheikh (2000), Mulatu (1999), Edman and Koon (2000) the attribution of causations to social and supernatural agents appears to be more common in non-western societies in contrast to western societies. In non- western cultures there is a tendency to attribute the causes of mental health problems to various social and religious elements. Williams and Healy (2001) also importantly assert that in their struggle to make sense of their experience, individuals might consider more than one cause for their problems.
In this chapter the themes are organized into three sections. The first section concerns the spiritual relationship with Allah, which was experienced as central in the explanations of the participants in the research. In this section I describe in detail how respondents discussed their mental health problems with a focus on how they perceived the causes of these problems. In order to provide a context for some participants’ explanations I commence this analysis with a description of the Islamic concept of relationship with Allah as it is described in the primary texts.
117 The second and third part of this chapter address themes that are related to the secondary causation of mental health problems, which I have labelled as spiritual and socio-political.
Section One: In Allah’s Will: the essence of the relationship (Spiritual context)
All themes that emerged from the analysis of the Qur’an and the Hadith, and from the analysis of participants’ interviews, pointed to the importance of the relationship with Allah when attributing a cause for mental health problems. In Islam the relationship with the creator is the basic primary indicator from which other secondary causations are interpreted as possible causations. It is the prime link which determines other relations with the rest of the universe. The relation with God is the basic element which shapes the relation of the individual with family and society. Everything in the universe follows certain rules of God.
It was clear from the analyses of the Qur’an and the Hadith that the conception of Allah’s will is central in the Muslim’s relationship with God, and in their interpretation of the causality of mental health problems. Allah’s will forms the core of the relationship of each person with God and this concept is by far the most important one within the Qur’an and Hadith, as well as for participants in this research. I also found that within the relationship with Allah four themes emerged as possible causes of mental health problem. Mental health problems might be ikhtibar a trial, blessing, or punishment, or Qadar destiny and fate. These themes also were strongly present in the discussions with participants.
In the Muslim’s relationship with God Allah is the creator and the human being is the creation of Allah. Oneness is the basic element in the connection with Allah. The role of the human being is to submit to the power of God, and to worship him alone. From the analysis of the texts of the Qur’an and the Hadith, I found the
118 importance of this relationship is frequently emphasized. An example of this concept is identified in the following verse:
Say ‘He is Allah the One and Only.’ (Qur’an 112:1)
The belief that Allah is the source of everything and anything, and that Allah’s power and knowledge is the ultimate power, forms the central understanding of this relationship. Everything is from Allah. Things happen only with his permission, and if he wills them. This notion is frequently identified in the Qur’an and the Hadith. Distress, illness, and health and any other difficulty in life, all come from Allah’s will. In the relationship God is the one who has the ultimate supremacy. Allah’s power is emphasized, as the following verses indicate:
To Him is due The Primal origin of the heavens and the earth When He decreeth a matter He saith to it: ‘Be’And it is.’ (Qur’an 2:117)
Allah alone possesses all power. He is the All-Knowing, the Powerful (Qur’an 42:50)
Within this oneness relationship, Allah is the one who has the ultimate knowledge. Allah knows what appears to us and what is hidden from our eyes. Allah encompasses everything and he is the one who perceives the true reality about things (Ibn Kathir 1966; Qutb 1979). This concept is mentioned frequently in the Qur’an and the Hadith. An example from the Qur’an is the following:
Know they not that Allah doth know their secret (thoughts) and their secret counsels, and that Allah knoweth well all things unseen. (Qur’an 9:78).
In this senses the truth about things, including the causation of mental health problems, is all within Allah’s knowledge. Human interpretations of what might be the source of their mental health problems are only endeavours. They are only possible interpretations which might be right or wrong. Humans’ knowledge is limited within the knowledge of Allah. This concept, which is frequently
119 mentioned in the Qur’an, strongly indicates the vulnerability of humans in their relationship with Allah the creator and the one who has ultimate knowledge:
It is Allah Who knows, and ye who know not. (Qur’an 3:66)
In spite of the Islamic notion that absolute truth and knowledge is within Allah’s reach, the search for interpretations is repeatedly encouraged in the Qur’an and the Hadith. Human beings, unlike other creatures, are expected to think and to have insight. They have the ability to rationalize things. There are many verses in the Qur’an which challenge individuals to learn and encourage reflective thinking about life events. Exploring is encouraged in the Qur’an and the Hadith as a moral obligation; human beings need to examine and evaluate in order to reach possible interpretations. Thinking about possible explanations is a process by which humans grow. It is seen as an essential way for strengthening the relationship with Allah. The search for knowledge is placed within the concept that Allah is the creator:
Verily in that are Signs for those who reflect. (Qur’an 30:21)
Searching for knowledge is seen as a continuing process of exploration. Humans are required to be flexible, to change interpretations and to accept new input. All of this is within the oneness relationship with Allah.
In describing reasons for their illness, the research participants noted the centrality of their relationship with Allah as that which was likely to be responsible for causing their mental health problems. The relationship with God is the essential factor which determines what sense individuals make of the causes of psychological problems. Within the Islamic philosophy, developing a strong, good relationship with Allah is considered to be a mission of human beings on earth. Any pain suffered on earth is interpreted within the context of each person’s relationship with the creator. There was frequent mention of Allah’s will being above human reach in the discussions of participants. Most participants, male and
120 female, with different level of religiosity, identified Allah as the source of both pain and healing.
It is interesting to note that Maryam, one of the female participants who identified herself as religious, talked directly about how health and illness are all Allah’s will:
God is the one who put the problem on you and he is the one who is going to take it away form you.
The belief in the power of Allah was frequently expressed by participants as part of their explanations and conversations. Mahmoud, one of the male participants, used a religious expression, which reflected this notion of Allah’s will, to summarize the cause of his mental health problems. He said:
It is Mashi’at Allah or ‘the will of Allah’.
The certainty of the power of Allah is seen as part of the Iman (strong belief in God). Participants considered the Allah’s power to be important. Many talked of their acceptance of this notion as an indication of their faith. The mental health problem is Allah’s will. For example, Sami, one male participant, noted:
The belief in Allah’s will is part of the belief in God, and in being a good Muslim.
Nida, a female participant who talked about her commitment to her spiritual relationship with Allah, explained how she believed that her psychological problem was because of the power of Allah:
It is Allah’s will and you can’t be a real mu’men (believer) unless you accept that.
The belief in Allah’s will as the source of psychological problems was seen as helpful in accepting the difficulties associated with a disorder. However, the level
121 of the acceptance of Allah’s will fluctuated. The belief in Allah’s will was considered a continuing process for some. Some of the participants talked about their struggle to keep reminding themselves of the notion of Allah’s will when thinking about the cause of their mental health problems. This struggle was seen as being due to the effects of the psychological problems. The reaching of the belief that the mental health problem is the will of God was considered to assist particpants in accepting the difficulties associated with mental health problems. Nour, one of the female participants, for example, reflected this process of seeking to achieve acceptance of Allah’s will:
Having depression is very hard, but I remind myself every day that I need to accept Allah’s will.
When the problem was perceived to have been caused by another source most participants stated that any other cause which might have caused their mental health problem (such as a social cause, or political problems) was only secondary to Allah’s will. Harm being caused by others or by any other reason cannot happen unless it was part of Allah’s will and within God’s knowledge.
Fouad, one of the male participants, indicated that the harm done by some people to him using sorcery, and possibly causing his mental health problem, was not the result of the abilities of the sorcerer, but of Allah’s will. Their influence in causing his mental health problem happened within the supremacy of Allah. He reflected:
So, I got hurt because of God’s will and not because of anyone wanting to hurt me’.
Nida, one of the female participants, reflected on how the hardships in her life and the problems in her relationships with relatives were all secondary causes of her mental health problems and all part of the will of Allah:
I have difficult circumstances. My life is not easy. It is Allah’s will.
122 Many of the participants talked about their journey in searching for the possible causes for their mental health problems. They followed different paths in order to make sense of the psychological problems. Most participants talked about several of the causes of their problems. In many cases these causations were considered only possibilities. The truth was considered to be within Allah’s reach. Mahmoud, one of the male participants, stated:
I don’t know for sure what might have caused my problems. Allah Aalam (God knows more).
Trial in Allah’s will
From the analysis of the Qur’an and the Hadith, as well as the findings from the discussions with participants, I found that trial is an important concept in relation to connection to Allah. It is believed that human beings were created to fulfil the role of worshipping Allah. The worshipping of Allah indicates the endurance of hardship and difficulties associated with life. Tribulations such as mental health problems are trials from God to differentiate between true believers and those who do not accept Allah’s will (Qutb 1979).
In this sense difficulties in life are to test the endurance and the patience of human beings. The passing of a trial is supposed to give a person an opportunity to be closer to Allah. Endurance of suffering is the way to get into heaven. Human beings are expected to strive to do their best in order to cope with problems. This notion is clearly identified in the Qur’an:
Or do you think that ye shall enter the Garden of (bliss) without such (trials) as came to those who passed away before you? They encountered suffering and adversity and were so shaken in spirit that even the Apostle and those of faith who were with him cried: ‘When (will come) the help of God?’ Ah! Verily, the help of God is (always) near’. (Qur’an 2:214).
123 Life in this sense is a competition. The goal of the competition is to build a good relationship with Allah. This is achived by being patient and by showing endurance. If an individual is affected by mental health problems, then this is part of their test. The idea of trial indicates that the faith of humans will be tested; consequently, pain, misfortunes, and difficulties are considered part of the human being’s life (El-Islam 1978) as identified by the following verse of the Qur’an:
‘Verily We have created man into toil and struggle.’’ (Qur’an 90:4)
The concept of mental health problems being a trial was frequently present within the participants’ responses. Their problems were considered a test from Allah to examine their tolerance. El-Islam (1978) argues that considering trials as a causation of mental health problems is clearly identified within other Islamic cultures where misfortune is considered an examination of the person’s patience and tolerance.
Baheera, one of the female participants, who identified herself as being highly religious, talked passionately about her mental health problem as being a trial:
It is a trial. I swear to God, I tell you this is a test form Allah.
Maryam was another female participant who described her psychological problem as a test of endurance:
My mental health problem is a trial from God.
Some participants considered their trial to have a purpose and to be the result of divine wisdom. Not having a mental health problem does not mean that a person is privileged in Allah’s eyes. A person with a mental health problem might be more accepted by Allah. Fouad, who indicated that he was struggling at an academic and social level due to his mental health problems, reflected this notion. He explained
124 how he was accepting of his difficulties in life as they were trials from Allah. Pain, accordingly, has wisdom within.
Every thing is a trial from God. Getting the best in life doesn’t mean that you are better than the others. Everything happens for a reason.
Some of the participants considered the intensity of their problem to be related to the level of their religiosity. The stronger the connection with Allah, the more a person would be subject to trials. Trials in this sense are considered a chance to get rewarded for the level of endurance. Baheera, one of the female participants who considered herself religious, stated:
Believers are more subject to be tested with misfortune.
Some participants discussed trials as part of Allah’s will. Having a mental health problem was seen to be is part of being a good Muslim. Being able to deal with the problem could only happen by making a better connection with Allah. Nida, one of the highly educated female participants, described features of her religiosity in order to strengthen her relationship with Allah. For her, being affected with mental health problem was considered a trial. The trial was Allah’s will.
Every one takes what God assigned to him. I pray for God to help me. The more religious you are the more you would be tested. Thank God there is nothing else I could have done.
As Allah’s will, any trial was considered by Firas to be just, even if it was as difficult or harsh as mental health problems. He reflected:
The Muslim person should believe that whatever you are getting is because of God. God is fair. If God is not fair, who would be?
125 Reframing the negative: The bright side of mental health problems
From the analysis of the Qur’an and the the Hadith, it became clear that difficulties and pain in life, such as mental health problems, might not always be considered a misfortune. They could be a blessing from God, or even a prevention ofsomething worse. While this is clearly stated in Islamic philosophy, not many participants discussed their situation in this manner. The positive side of pain is presented in the Qur’an in verses such as this:
But it is possible that ye dislike a thing which is good for your, and that ye love a thing which is bad for you. But God konweth and ye know not. (Qur’an 2:216)
Difficulties in life might be an opportunity to be granted Hasanat, or rewards in this life and the hereafter. As a consequence of endurance and the accepting of Allah’s will, a person with a mental health problem will be blessed by Allah. Dealing with pain is thus an opportunity. If an individual accepts the difficulties and the misfortunes of life with patience and tolerance, the Qur’an says:
Be sure we shall test you With something of fear and hunger, some loss In goods or lives or the fruits (Of your toil), but give Glad tidings to those who patiently persevere, Who say, when afflicted With calamity: ‘‘To God We belong and to Him Is our return’.’ (Qur’an 2:155, 156)
Painful experiences, as became clear from the analysis of the Qur’an and the Hadith, are a sign of Allah’s love for the Moumen, ‘the strong believer’. They are to be considered a blessing from God. The purpose of suffering and pain is to strengthen the sufferer’s relationship with the creator. The pain is from Allah and the healing from the pain is from Allah also. This means that the individual needs to become closer to Allah by strengthening their spiritual side and putting more balance into their life. The Prophet Muhammad said in the Hadith.
126 No fatigue, no disease, nor sorrow, nor sadness, nor hurt, nor distress befalls a Muslim, even if it were the prick he receives from a thorn, but that Allah expiatessome of his sins for that (Sahih Bukhari v7 p. 307).
Never a believer is stricken with discomfort, hardship or illness, grief or even with mental worry that his sins are not expiated for him (Sahih Muslim p.1364).
As mentioned earlier, not many participants talked about mental health problems as being a blessing from Allah. Participants talked about the notion that mental health problems, like any other distresses, are a blessing in disguise, rahma or ‘mercy’. Suffering from a mental health problem occurs in order to prevent more difficulties and distress.
Ali, one of the young male participants, said:
Difficulties in life are rahma.
Maryam, one of the female participants who considered herself religious, expressed passionately that her mental health problem was a blessing from Allah:
The closer you are to Allah, the more you will face difficulties in life.
Many of the participants indicated that they became more committed to the practice of their religion after being affected by mental health problems. This was because they perceived their psychological problems as a trial, Qadar, or possibly as a result of being away from Allah. Many accepted the problem as an opportunity to become closer to Allah and an indication that they needed to strengthen their ties with God.
Jameel, one of the male participants, talked about the change in his attitude and practice of religion after the experience of a mental health problem.
127 I became more religious after I was affected by the illness.
Punishment and estrangement: When not keeping the relationship with Allah
From the analysis of the Qur’an and the Hadith it became clear that mental health problems might be a result of not obeying Allah’s commands. Mental health problems, then, like any other difficulties or distresses in life, might be a result of lack of faith and a punishment.
A mental health problem could be considered a punishment for the wrongdoing of an individual. The consequences of a bad act might lead to a negative effect on individuals. This notion is discussed by Muslim scholars such as El-Islam (1978). On the other hand, Al-Issa (2000e) argues that being affected with a mental health problem is not considered a punishment for individuals who have a strong relationship with Allah. The notion of punishment is mentioned in the Qur’an, as the following verse indicates:
Whatever misfortune happens to you, is because on the things your hands have wrought, and for many (of them) He grants forgiveness (Qur’an 42:30).
The Prophet says in the Hadith:
Whoever has done evil will be requited for it (Sahih Muslim p. 1364).
The punishment is considered just, as it is a result of the wrongdoing of a human being.
Verily God will not deal unjustly with man in aught: It is man that wrongs His own soul (Qur’an 10:44).
Being away from Allah, disobeying Allah’s commands, committing sins, and a lack of trust in Allah, are considered the possible causes of depression, anxiety, and
128 other mental health problems as became apparent from the analysis of the Qur’an and the Hadith. This is also asserted by Ahmed (1998) and Yarkindi (2000), who reflect this notion by arguing that mental health problems might be caused by not following Allah’s instructions, and consequently will possibly be punished by mental health problems. Being affected with psychological problems as a result of being away from Allah is identified in the following verse of the Qur’an:
Whosoever follows My guidance, will not Lose his way, nor fall into misery. But whosoever turns away from My Message, verily for him is a life narrowed down, and We shall raise Him up blind on the Day of judgment. (Qur’an 20: 123,124).
Individuals committing sins could be punished in life with mental health problems. The punishment in life is a way of reducing the punishment in the hereafter. Like any other difficulty in life it is an expiation and a cleansing of sins. The Prophet says in the Hadith:
When a Muslim falls ill, his compensation is that his minor sins are obligated just as leaves fall (in autumn) ( Sahih Muslim p. 1365).
Mental illness could be caused by feelings of guilt for wrongdoing. Feelings of guilt to the extent where the person becomes psychologically affected are prevented by the belief that Allah forgives all sins if the person asks for forgiveness and works towards it. Guilt is acknowledged in the Qur’an as a cause of distress and sadness for human beings:
Say: ‘O my servants who have transgressed against their souls! despair not of the Mercy of Allah: for Allah forgives all sins: For He is oft-forgiving, most merciful’ (Qur’an 39:53).
A small number of male participants considered their mental health problems to be caused by a lack of faith. They considered that true faith would work as a protector from any mental health problem. Any psychological problems were considered by those participants to be related to punishment.
129 While most participants said that mental health problems might affect individuals who are strong believers in Allah, and as was discussed earlier, many considered the cause was related to a trial, for believers in Allah, a small number of male participants discussed the possibility of mental health problems being caused by being away from Allah.
Ali, one of the male participants, considered that mental health problems were caused by lack of faith, which might weaken human beings and make them vulnerable to being affected by mental health problems. Strong faith was considered to be a protection for the believer from any mental health problems.
Psychological problems are related to lack of faith. It is because my faith is not complete. I am sure a person, who has real faith, wouldn’t be affected with these problems. I mean whatever happens to this person, it wouldn’t affect him, or cause him psychological problems.
Jameel, another highly educated male participant who indicated that he had recently become more committed to practising religion, explained how difficulties including mental health problems affected human beings as a result of their not keeping a strong connection with Allah:
There are many things that affect human beings when being away from God. This person would then feel depressed and anxious.
Firas, another highly educated male, discussed how faith can save a person from any harm. For him, true believers are not affected with psychological problems.
Being close to Allah and following the religion protects people. I do not think any one who is a true believer will be affected. Whoever feels that he is suffering in life wouldn’t be a real believer.
In spite of the presence of punishment in the Qur’an and the Hadith (Qur’an 10:44), only a couple of male and no female participants discussed this aspect as a cause of their mental health problems. A small number of male participants
130 indicated that their disorder was probably a punishment for straying from Allah, and for not being a good Muslim. Mahmoud, for example, told me:
I became ill when I strayed from God. I used to be a much better Muslim before, but then I started to get weaker and had changed a lot. I stopped reading the Qur’an like I used to. I started to commit some sins which I never used to. The sins seemed easier to commit then.
Firas, another male participant, considered his homosexual behaviour as a punishment for his mental health problem. Homosexuality is considered a sin in Islam (Qur’an 26:165). Engaging in homosexual acts consequently brings feelings of guilt which lead to interpreting mental health problems as being a punishment for homosexual orientations. The young male participant who indicated that he had started practising Islam recently but had always been a believer in Allah talked regrettably about his sexual experience as a strong possible cause for his mental health problem.
(Hesitantly) I used to have a relationship with a younger man. I was in my early teenage years when I started the relationship with him. The relationship continued until I decided to terminate it and went to study in another country. The relationship continued until I was 18 years old. The relationship had a strong negative affect on me. It led to the psychological problem I am suffering from.
Qadar (fate): the power of Allah
The notion of Qadar (fate) as being part of Allah’s will is an important part of the individual’s in the relationship with Allah as many Muslim scholars have indicated (Qutb, 1979; Ibn Kathir 1966). In the Qur’an and the Hadith there is frequent mention of Qadar. The notion of Qadar is that everything that happens to us has been decided before we are born. Mental health problems, whether they are a trial, a punishment, or a blessing, like other things in our lives are Qadar. They are predetermined within Allah’s power and knowledge. All is within Allah’s will. The belief in fate is considered part of Islamic belief. This notion is clearly stated in the Qur’an and the Hadith, as seen in the following verse of the Qur’an:
131 Say ‘nothing will happen to us except what God has decreed for us’ (Qur’an 9:51).
In the Hadith of the Prophet there is a clear statement of the divine predetermination of the fate of human beings, which is decided by Allah, even before a person is born. A mental health problem is one of the possibilities that is predetermined for a person:
The matter of the creation of a human being is put together in the womb of the mother in forty days, and then he becomes a clot of thick blood for a similar period. Then Allah sends an angel who is ordered to write four things. He is ordered to write down (the new creature’s deeds, his livelihood, his (date of) death, and whether he will be blessed or wretched (in the hereafter) (Sahih Bukhari v 4 p. 276).
Being affected with a mental health problem is Allah’s will. Feelings of regret or thinking about what possibly could have been done to avoid it will only make things worse for the person. Thinking of the past will only make a person vulnerable. The Prophet says in the Hadith:
Should you come across some mishap, do not say: Had I only done this and that things would have turned out so and so; but say only Allah so determines and did as he willed; because the phrase; ‘had I only opens the gates of evil conduct nd Islam (Sahih Muslim, cited In Nawawi p. 76)
Some participants talked clearly about mental health problems as a part of their fate, as something predestined for them. Some participants talked about how the certainty of Qadar was part of their belief in Allah. It was seen as an essential part of their religious beliefs. A mental health problem is something which is decided by God as part of his will. This belief needs to be genuine as part of the Iman or belief in Allah. Accepting Qadar is considered an important part of Iman. Burhan, one of the male participants, reported:
The belief in Allah’s will and the Qadar is part of the Islamic beliefs. The believer should not only believe in it but also practice it and prove his acceptance. What happened to you wheather it was good, bad, or grace or
132 anything, is from god. Everything is predetermined by Allah and you need to be patient. The condition of Belief in Islam, in addition to the belief in God and the Prophet, then praying, charity, fasting, and then the pilgrimage, is to believe in destiny whether it is good or bad.
Fouad, one of the male participants who identified himself as religious, talked about his Qadar of being affected by psychological problems. He discussed his acceptance of the problem because it is Allah’s will:
I believe that this ‘mental health problem’ is part of my Qadar. It is something which was predetermined for me. It is Allah’s will. I am a believer in Allah and I know that believing in Qadar is part of my Iman or faith. I can’t change that. I am accepting of it.
Nida, a female participant, reflected in her discussion her belief in mental health problem as being Qadar. She stated:
Everyone takes what God has assigned to him.
The belief that mental health problems are Allah’s will was strongly present among participants when they talked about family members and how they perceived the causation of the problem. The beliefs of the family members enforced the notion that mental health problems are Allah’s will.
Fouad reported how his mother perceived the causation of his problem as being part of God’s will:
My mother is an elderly lady, she is not educated. She always says to me ‘It is Allah’s will’. It is Naseeb (‘destiny’).
In summary, the notions of mental health problems being Allah’s will, a trial, punishment, and Qadar, are mentioned frequently in the Qur’an and the Hadith. These concepts were also seen to have clearly influenced participants both directly and indirectly as they referred to the causes of their mental health problems. Most
133 male and female participants considered their mental health problems as being Allah’s will. Most of them considered the problems to be trials that were part of Allah’s will. The analysis of the Qur’an and the Hadith showed that even individuals who have a strong relationship with Allah might be tested with a mental health problem. In the next section, I will address a arrange of secondary causations that emerged from the analysis of the Qur’an and the Hadith, and from the interviews with participants. These are: Jinn, hassad, and sorcery.
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Section Two: The Spiritual World: The Invisible power
In this section I will address another important attribution of the cause of mental health problems within Islam. This is spiritual power, which is referred to as Jinn, sorcery, and the evil eye. The attribution of supernatural power as the cause of mental health problems is well documented in many Muslim communities. Research shows that these beliefs are found in: Pakistan (Mubbashar, 2000), some African societies (Lamensdorf Ofori-Atta & Linden 1995), Ethiopia (Mulatu 1999), Malaysia (Edman & Koon 2000), Algeria (Al-Issa 2000b), Kuwait, Qatar (El-Islam 2000), and Jordan (Al-Krenawi et al. 2000). The study of religion and magical power was the centre of attention in the literature which discussed the attribution of mental health problems (Lamensdorf Ofori-Atta & Linden 1995). In Islamic culture, spirits, both bad and good, are seen to affect human beings. For example, bad spirits are seen to be the source of mental health problems, as many scholars have asserted (Al-Krenawi & Graham 2000a; Ng 1997; El-Islam 2000; Al-Issa 2000a). While Edman and Koon (2000) assert that the supernatural attribution of mental health problems is influenced by age and level of education, El-Islam (2000) asserts that it is not influenced by level of education. The influence of Jinn, sorcery, and the evil eye, are placed within Allah’s will and the context of a person’s relationship with Allah whether this entails Qadar, a trial, a blessing, or a punishment.
Jinn: The invisible nation
Many Islamic scholars suggest Jinn is the cause of various health problems, including mental health problems such as ‘depression’ ‘anxiety’ and ‘tension’. A belief in the existence of Jinn is considered to be an important part of Islam (Ibn
135 Taymiyah & Philips 1989; Ameen 2005). Dols and Immiscch (1992) and Sheikh (2005) argue that the subject of Jinn is complex in Islamic beliefs. They further argue that, in spite of the mention of Jinn in the Qur’an and the Hadith, not much explanation of what Jinn entails is given. Ameen (2005) explains that the word Jinn in Arabic refers to something that is concealed and hidden. Ibn Taymiyah argues that important scholars maintain that the word comes from the verb Janna which means ‘to hide’ (Ibn Taymiyah & Philips 1989 p. 1). Ad’ham (1993) argues Jinn means to conceal things from the five senses of human beings. Jinn is mentioned on many occasions in the Qur’an and the Hadith which state that Jinn are created from fire:
And indeed, We created man from dried (sounding) clay of altered mud. And the Jinn, We created … from the smokeless flame of fire’ (Qur’an 15:26,27).
In the Qur’an there is a mention of the abilities of some of the devils of the Jinn. They are granted skills such as diving into the deep seas and entering into buildings. The Qur’an says:
And also the Shayaateen (devils) from the Jinn (including) every kind of builder and diver (Qur’an 38:37).
Ibn Taymyiyah and Philips (1998), and Ameen (2005), explain that the subject of the existence of Jinn is controversial among Muslim scholars. While the majority believe in the presence of Jinn, some do not. Ad’ham (1993) argues that some Muslim scholars reject the idea of the existence of Jinn to the extent that they refuse to enter into any argument about its reality. These are the ‘Madeeon’ or materialistic philosophers. These philosophers deny the existence of spiritual things that are not able to be seen or sensed. Ad’ham (1993) explains further that Ibn Maja’a, a famous Muslim philosopher, is one of thosethinkers. Ibn Maja’a denied the existence of worlds which we cannot sense, pointing out that these are the product of the imagination of human beings.
136 Ad’ham (1993) also notes that other philosophers, such as Ikhwan Al-Safa, claim that Satan is an evil human being who might harm others through their bad deeds and behaviour. On the other hand, angels are good human beings who are good to others.
He further explains that the description of Jinn is also subject to various discussions among theologians. Some consider the definitions of Jinn without discussing details of their nature or proving their existence. Some Muslim scholars are concerned with the descriptions of Jinn and whether they have senses such as hearing or sight. Some, for example, Farabi, Al Ghazali and Ibn Sina, describe them as being airy creatures which have the features of animals. Other scholars talk about the ability of Jinn to appear as cows, sheep, horses and donkeys. Shahawi (1994) notes the descriptions of Jinn by some scholars as black dogs which are considered devils, and that they are of both sexes and organized hierarchically with leaders. Dols and Immisch (1992 p. 213) explain how Jinn are considered by some as intelligent living beings, created from ‘smokeless flame’.
Ibn Taymiyah, an important Muslim scholar, describes Jinn thus:
The Jinn are being created with free will, living on earth in a world parallel to that of man, and are invisible to human eyes in their normal state. The Arabic word Jinn comes form the verb Janna which means to hide (Ibn Taymiyah & Philips 1989 p. 1).
According to Islamic beliefs, Allah created al-ins (human beings) and Jinn to worship him (Dols & Immisch 1992). Both humans and Jinn have an obligation towards Allah. In this relationship, Allah is in no need of humans or Jinn but they need him.
In Islam there is a belief that Jinn are creatures with free will. They are ordered to worship Allah and accordingly they will be rewarded for good deeds or punished
137 for wrongdoings (Ibn Taymiyah & Philips 1989). For example, the Qur’an states about the purpose of the creation of Jinn:
I created the Jinn and humankind only that they might worship Me. I seek no livelihood from them. Nor do I ask that they should feed me (Qur’an 51:56,57).
While both humans and Jinn are created to worship Allah, humans are privileged over all other creatures including Jinn. In other words Jinn are considered to have a lower status than human beings. The privileged status of humans over the rest of the creation is mentioned in the Qur’an in the following verse:
And indeed We have honoured the children of Adam, and We have carried them on land and sea and have provided them with (lawful good things) and have preferred them above many of those whom We have created with a marked preferment (Qur’an 17: 70).
This preferred status created jealousy in the Jinn towards human beings. The Qur’an tells the story of the origin of this envy. Iblis (Satan) was the first Jinn to disobey Allah:
We created man from sounding clay, from mud moulded into shape; And the Jinn race, We had created before, from the fire of a scorching wind. Behold! thy Lord said to the angels: ‘‘I am about to create man, from sounding clay from mud moulded into shape; ‘‘When I have fashioned him (in due proportion) and breathed into him of My spirit, fall ye down in obeisance unto him. So the angels prostrated themselves, all of them together: Not so Iblis: he refused to be among those who prostrated themselves. Iblis) said: ‘‘I am not one to prostrate myself to man, whom Thou didst create from sounding clay, from mud moulded into shape.’’ Jinn were sent to earth like human beings ((Allah)) said: ‘‘Then get thee out from here; for thou art rejected, accursed (Qur’an 15: 26-34).
In Islamic tradition there is a belief that the Jinn had more power before the start of Islam. They used to know the ghib or the future by getting closer to heaven, eager to explore news that affected the earth and what was happening in heaven. They lost this power before the revelation of the Qur’an.
138 There is also mention about Jinn being prevented from hearing news of the future.
‘We used, indeed, to sit there in (hidden) stations, to (steal) a hearing; but any who listen now will find a flaming fire watching him in ambush’ (Qur’an 72: 8,9).
Some Jinn investigated and when they listened to the Qur’an they liked what they heard, and consequently embraced Islam, and started to invite other Jinn to do the same. There is a mention in the Qur’an and the prophetic tradition of the embracing of Islam by some of the Jinn who listened to the Qur’an and believed in Allah and the Prophet Muhammad. The Prophet’s message is for both human beings and Jinn (Ibn Taymiyah & Philips 1989). As the Hadith says:
Allah’s messenger went out along with a group of his companions stewards Ukaz market. At that time something intervened between the devils and the news of the heaven, and flames wree fired upon them, so the devils returned. Their fellow- devils said ‘‘What is wrong with you?’’ They said ‘‘something has intervened between us and the news of the heaven, and fires (flames) have been shot at us’’ Their fellow-devils said ‘‘Nothing has intervened between you and the news of the heaven, but an important event has happened. Therefore , travel all over the world, east and west, and try to find out what has happened’’ And they set out and travelled all over the world , east and west, looking for that thing which intervened between them and the news of the heaven. Those of the devils who had set out towards Tihama, went to Allah’s Messenger at Nakhla (a place between Makkah and Taif) while he was on his way to Ukaz market (They met him) while he was offering the Fajir prayer with his companions. Then they heard the Qur’an being recited (by Allah’s Messenger). They listened to it and said (to each other). This is the thing which has intervened between you and the news of the heavens. ‘‘then they returned to their people and said ‘‘ O our people, Verily We have heard a wonderful Recitation (the Qur’an Ot guides to the Right path, and we have believed therein, and we shall never join in worship) any thing with our Lord ( Allah) ( Sahih Bukhari v 6 p. 370).
The Qur’an also describes the embracing of Islam by some of the Jinn:
1. Say: It has been revealed to me that a company of Jinns listened (to the Qur'an). They said, 'We have really heard a wonderful Recital! 'It gives guidance to the Right, and we have believed therein: we shall not join (in worship) any (gods) with our Lord (Qur’an 72:1-2).
139 While some Jinn are considered to be believers, others are non-believers, as Dols and Immisch (1992) explain. Ibn Taymiyah and Philips (1989) argue that in Islamic philosophy the Jinn who do not believe in God are considered devils. In the Qur’an there is mention of the Jinn stating differences among themselves in terms of some being believers and others non-believers:
There were some foolish ones among us, who used to utter extravagant lies against Allah (Qur’an 72:4).
Dols and Immisch (1992) argue that in most Islamic scholarship there is a belief that there are two sorts of spirits: good and bad. A good spirit is one that believes in God and will not hurt individuals who have a good relationship with God. The bad spirit is one that follows Satan or what Muslims call Iblis. Iblis in Islamic belief is the responsible agent for many sins and wrongdoings by human beings. The Jinn that cause harm are the non-believers. It is believed that every human being has a Jinn with which they are associated.
The bad Jinn are described in the Hadith as having an effect on human beings.
Verily Satan flows in the blood stream of Aadam’s descendents (Ibn Taymiyah & Philips 1989 p. 17).
The bad Jinn might have an influence on human beings, and suggest ideas which might cause psychological problems such as obsession. However, these effects are not clearly mentioned. In any case the work of Satan or the bad Jinn is considered frail and weak. Jinn can only harm people if they are not safeguarding their relationship with Allah.
Ever feeble indeed is the plot of Shaytaan (Qur’an 4:76).
140 When assessing the effect of Jinn on the mental health of humans, Muslim scholars have different opinions. Some say they are the main cause of mental health problems, while others say the cause of the problem not explained. Some claim that the cause of psychological problems that are not explined in medical terms could be Jinn (Shahawi 1994). Some claim Jinn as the direct cause, while others maintain the ambiguity of the subject and its relation to mental health problems. In spite of the indication of the existence of Jinn in the Qur’an and the Hadith, their effect on humans and on mental health problems is not clearly explained.
Ameen (2005) argues that individuals adopt different views about Jinn. Some of these are culturally and not religiously based and influenced. Some of these views might vary within a culture, based on an individual’s beliefs and education. Dols and Immisch (1992) argue that the belief in spirits and possession was strongly present in the Arab culture before the start of Islam. They point also to the influence of Judaism and Christianity, both of which express beliefs in spirits.
Sorcery in Islam: The Sihr
Sorcery is mentioned in the Qur’an and the prophetic traditions on many occasions. It is a forbidden practice. Ibn Taymiyah and Philips (2000) note that in Arabic Sihr, or sorcery, means the unseen and the concealed thing. Sihr can have a negative effect on the physical, emotional or mental state of a victim, causing health and relationship problems, or in some cases death. Al-Issa (2000c) and El-Islam (2000) argue that sorcery means causing people harm by using evil spirits. This is usually done through a witch who practices the art of magic to possibly affect others and their psychology. For example a man might want to influence a woman whom he loves and who does not feel the same way about him. Or a woman might try to minimize the interference of her in-laws.
Jamal (1985) claims that sorcery is generally regarded as the work of a person who has special secret characteristics and potentials that she/he uses to affect other
141 individuals or groups of people. Qutb (1979) explain that sorcerers impose things on people against their will. On many occasions in the Qur’an and the Hadith, sorcery is mentioined as the cause of social and psychological problems in the lives of human beings. The practice of sorcery or using a sorcerer for any reason is forbidden within Islamic teaching and tradition. It is considered a sin. The Prophet says in the Hadith:
Avoid practicing magic (Sahih Muslim and Sahih Bukhari) (cited in Nawawi & Abbasi 1980 p. 786).
Practising, learning or teaching magic is considered to be Shirk or disbelieving in Allah. It is a way in which the devils encourage humans to turn away from asking Allah’s help and accepting his will. The Qur’an states:
but the Shayaatin (devils) disbelieved teaching men magic (Qur’an 2: 102).
In the Qur’an there is a mention that practicing Sihr means asking for help from a source, but not from God. It is associating partners with Allah. The practice of sorcery contradicts the belief in the oneness of Allah, which is a basic belief in Islamic philosophy. It is a way of asking others to solve problems or to provide help instead of asking Allah.
Verily whoever sets up partners with Allah, then Allah has forbidden Paradise for him and the fire will be his abode. And for the Zalimun (polytheists and wrongdoers) there are no helpers (Qur’an 5:72).
The Prophet praises believers who do not practice sorcery.
They are those persons who neither practice charm, nor ask others to practice it, nor do they take omens, and repose their trust in their Lord (Sahih Muslim p. 42)
142 In the Qur’an there is an assurance that the effect of sorcery is still within Allah’s will.
And the magician will never be successful whatever amount (of skill) he may attain. (Qur’an 20:69)
Jamal (1985) suggests that there is controversy among scholars about whether Sihr is real or not. Most Muslim scholars believe in the existence of sorcery. Others state that it exists only in the imagination. Jamal explains that the Mu’tazilah, for example, rejected the existence of sorcery and its effects. Ibn Taymiyah and Philips (2000) argue that sorcery is real and that the Prophet himself was exposed to Sihr or sorcery. Jamal (1985) notes that Alshafi, one of the important Muslim scholars, asserted that Sihr affects people and makes them sick, mentally unstable, and sometimes kills them.
Jinn and perception of Sorcery among Participants
In spite of the belief of the existence of the Jinn (Qur’an, (51:56)) and the effect of sorcery (Qur’an, 113:1-5) as mentioned in the Qur’an and the Islamic traditions, most participants thought no relation existed between their mental health problems and Jinn. This is different from what most studies in Muslim societies have found. In the literature in Islamic societies there is an emphasis on attributing mental health problems to supernatural powers. While some studies claim that older generations and females might have a stronger tendency to attribute mental health problems to the supernatural (El-Islam, 2000), in this study, there were no differences in gender, age, or educational levels in relation to attributing the causes of mental health problems to Jinn or sorcery.
No effect: At least in my case
While most studies conducted in non-western cultures (Gopaul-McNicol, 1997) or Muslim cultures (Al-Subaie & Al Alhamad 2004; Alsughayir 1996; Al-Krenawi
143 1999a) indicate that individuals tend to attribute their mental health problems to spiritual forces, this study found that few participants attributed the causes of their mental health problems to spiritual forces. Most of the participants in this study believed in the existence of Jinn and the possibility of sorcery because they are mentioned in the Qur’an and the the Hadith. There was also consideration that Jinn and sorcery might have an effect on other people’s mental health problems but not in their own cases.
Hannan, one of the female participants who identified herself as religious, reported that she believed in the presence and the effect of the invisible power. Yet she rejected the idea that this power had any effect on her in relation to her mental health problem:
I believe in sorcery, and that there are Jinn. I believe in that because it is mentioned in the Qur’an, but Jinn have no effect in my case. No.
Firas, a male participant, who considered belief in Jinn as part of Islamic beliefs, talked confidently about the possible effect of Jinn on human psychology:
I believe in Jinn and sorcery. It is mentioned in the Qur’an.
When participants talked about the possible effect of Jinn and sorcery in causing mental health problems, they used verses of the Qur’an or the Hadith. The use of these verses was to make the link between what they think and their religious beliefs. Nour, a female participant, reflected on how her belief in the existence of sorcery and Jinn was based on her Islamic beliefs. She mentioned a story from the Hadith, in which there is mention that the Prophet himself was bewitched by one of his enemies (Sahih Muslim p. 1192):
The Prophet himself was affected by it. The belief in the effect of Jinn and sorcery is part of our religious beliefs. We can’t contradict it.
144 Some participants talked about Jinn or sorcery causing psychological problems in other people. Sorcery was more likely to be linked to more intense mental health problems. Hannan, one of the female participants, discussed the symptoms which might be caused by sorcery, and stated that her depression and anxiety were not caused by it:
Sorcery would make individuals, and their spirits tired. But I do not feel there is any effect of that sort in my case.
She further confirmed that her case was not related to sorcery or Jinn by making a comparison with her sister who had been diagnosed with schizophrenia. In these cases the possibility of the effect of Jinn and sorcery is seen as more relevant. The evidence of sorcery and Jinn may also be identified by close family members:
My problem is not related to Jinn or sorcery but I think it might have an effect in my sister’s case. We as a family are sure that her case is a result of sorcery. We also know who did that to her.
Some participants indicated that there was a link between the affect of Jinn and not having enough faith. Ideally believers are not affected by the Jinn. Having faith and reading specific Ayat (verse) of the Qur’an provides protection. Nour, one of the female participants, stated how she was protected from the effect of Jinn because of her Iman or strong belief in Allah:
Jinn can harm those individuals whose faith is weak. But it wouldn’t affect me.
Some considered the subject to be a mere superstition. They attributed other social and political circumstances as the main cause and omitted any spiritual causation. Suad, one of the female participants, reported how she reacted to people anticipating that her problem might be due to sorcery or Jinn. She was definite that her faith guarded her from these sorts of effects.
145 Personally, I don’t believe in these things. I laugh when people discuss the subject. I mean if you have a problem of that sort just read the Mu’awwadhatain (Qur’anic verse) and everything will be fine.
For Hussain, one of the male participants, who indicated that he was not a practicing Muslim, social and political circumstances were considered the main causes for his psychological problems. He denied any spiritual causation:
It is the regime in the world which is responsible for psychological problems. I don’t believe in superstition.
Some decided to exclude the effect of Jinn from their case after listening to educational and religious programs on TV and radio. These programs talked about the effect of mental health problems and warned against falling into the traps of fraudulent Sheikhs who might use supposed possession by Jinn to mislead some individuals with mental health problems.
Sami reported this type of experience:
I was watching a program on TV about mental health. There was a big argument between a doctor and a Sheikh about the effects of Jinn. The doctor said that it is a psychological problem and the Sheikh was a fraud. The argument of the doctor was more convincing.
Alwan, one of the male participants, went to a Sheikh to discuss the possibility of any effect of Jinn or sorcery on his psychological problems. At these sessions the Sheikh read the Qur’an to help get rid of the effect of the bad spirit. When the mental health problem persisted then the decision was made that it was a psychological problem which required professional intervention.
At the start I used to think that there was an effect of that sort ‘sorcery or Jinn’. I investigated the subject. I tried to learn more about it. I met with people who have an understanding of these things. I mean the understanding of Jinns and that sort of thing. But I concluded that it has no relation to my case. To the extent where I am convinced now it is an illness, it is a normal sort of illness, and it could be treated.
146 Mental health problems could have a different causation from that assumed by the family of the sufferer. Muhseen, one of the male participants, reported the differences between his and his mother’s perceptions when it came to the possible causation of his mental health problem:
My mother thinks my problem is caused by sorcery (laughing). Of course I do not believe that. It is a psychological problem.
Hesitantly: Yes, possibly it has an effect on my case
Some of the participants who talked about the possibility of the effect of sorcery and Jinn did so hesitantly. Some of the their expressions indicated some defensiveness. Fouad reflected on his conflicting ideas about the subject and how he had tried to make sense of the possible causes:
I sometimes feel that the subject may be more than an obsessive-compulsive disorder, may be there is something more dangerous [Jinn or sorcery] than the obsessive-compulsive disorder. I do not know [laughing]. I do not know. I have no idea. But I am also trying not to think of it in that way … I think if the problem was caused by Jinn it would have been cured by now [meaning after reading of Qur’an].
Some discussed their difficulty in deciding whether their problem was caused by the effect of Jinn or was due to other causes. Firas, one of the male participants, talked about the complexity of identifying the effects of Jinn or sorcery:
The problem is how to specify whether the psychological problem is because of the Jinn or because of something else.
He further discussed that the facts about the real causes are out of reach of human beings:
I do not think there is a way. It is all within Allah’s knowledge.
147 Some initially considered the effect of Jinn and sorcery as this was recommended or interpreted by others such as family members or friends. A belief in the effect of Jinn and sorcery was part of their journey of coming to terms with their disorder. This was especially so when the disorder had been sudden and intense.
Sami, one of the male participants, reflected on how the effect of the mental health problem left him vulnerable to believing in the effect of Jinn in his case. This was in spite of having not believed in the effect of possession prior to being affected by the mental health problem.
I never believed in these things, but when the problem happened to me, and everyone was suggesting different things, I started to believe them. To be honest, I knew this wasn’t true, but then I needed anything, any hope.
He further clarified:
A fraud Sheikh told me that sorcery was the cause of my case. I used to have tension in my chest whenever I had a problem, [laughing]. I sort of believed him. I mean I didn’t believe them, but I needed that. I was hoping to find a treatment.
Some gradually reached a point of excluding the effect of Jinn and sorcery, after accessing the clinic and improving with medication. Muhseen, one of the male participants, stated:
I used to tell myself it might be sorcery, but then when I came here and got better with medication, I knew it is an illness.
Has an effect on my case
A small number of male and female participants thought of Jinn or sorcery was the cause of their mental health problems. Maryam discussed how her problem was caused by sorcery initiated by others:
148 My husband and I believe in sorcery. My psychological problem is because I was exposed to sorcery. I am pretty certain.
For a small number of participants it was the sudden onset of a mental health problem that indicated the effect of Jinn or sorcery. Rania, one of the female participants, reflected:
I used to be healthy and happy. I became ill all of sudden. Everything changed at once. My family and I believe it is sorcery.
In spite of thinking that sorcery was the cause of their mental health problem, male participants discussed the subject in a defensive tone. Fouad, one of the male participants, described with less certainty than any of the female participants the effect of Jinn and sorcery:
The cause might also be sorcery. These things are there. There is nothing wrong in believing in them. Nothing is wrong in saying I am affected by sorcery and Jinn. I could have been affected by it.
Some said that they were told by family members or friends that sorcery or Jinn could be the cause of their problem. Sorcery is mainly thought to be initiated by jealous individuals, such as in-laws or relatives. Most of those who thought they were affected tried to find who might have carried out the sorcery. Rania, one of the female participants, said:
I was told by people that my mother-in-law could have done sorcery to harm me.
It seems there is common cultural knowledge among various Arabic cultures about the characteristics of sorcery and the effects of Jinn.
Rania, who accessed the help of Sheikhs in many Arabic countries in order to investigate the cause of her problem, reported:
149 They said the same thing in Egypt, Syria, the West Bank, and in Jordan. They all said that I have eaten something to prevent me from enjoying my wedding and marriage.
Fouad, one of the young male participants, described how he thought the sorcery was possibly initiated by relatives or people who were jealous, or had aggressive attitudes towards him:
Relatives or people who I might have been compared with might be the ones who used sorcery on me. I mean people who might be envious of my success. Instead of competing by making an effort those people try and stop my efforts. [He meant forbid him by sorcery].
He told me that Jinn and sorcery had initiated his psychological problem, but that he was now cured of them. Now the reason for his problem was psychological rather than spiritual:
I used to have something [effect of Jinn or sorcery] at the start of my psychological problem, but not any more
Prior to being affected by mental health problems he did not believe in the effect of sorcery, but then he started to after discussions with relatives and friends and talking to Sheikhs.
At the beginning I rejected the possibility of the effect of Jinn or sorcery altogether. But then I tried the Qur’anic healing, and as soon as the Qur’an was read on me I felt the agitation diminishing.
The harm caused by sorcery is still related to Allah’s will. It is part of the person’s Qadar or destiny. As Fouad commented:
It is God‘s will that specific people harm others by Sihr, but I would get hurt because of God’s will and not because of them wanting to hurt me by sorcery.
150 Some attributed sorcery as the cause of their mental health problems, but blamed themselves for their weakness, saying they were affected because they had Istidad – the potential or the vulnerability to be affected.
Ali reported that his personal traits were the main reason for his being affected by sorcery or Jinn:
I wouldn’t get affected by sorcery unless I have the istadad. In my case I say I have a specific weak point in my personality, which had led to this outcome.’
Fouad explained his point of view in relation to the effect of sorcery:
When I looked into that in a scientific way, in a religious scientific way, I found that sorcery is there and we have to believe in it. The way they explain it religiously is that sorcery is a work contract between Al-saher [the person who practices sorcery] and the bad Jinn [demon]. Based on this contract the bad Jinn enters the human body and starts affecting it. As long as the sorcery is there the demon will be there causing confusion for the person. When the demon is forced out of the body, the person will go back to being normal.
He further explained that he was not sure about the nature of the effect, but that with the advancement of science humans might be able to better understand the influence of Jinn and sorcery. He adopted a theory which made sense to him of the possession of humans by Jinn. The explanation was based on a scientific TV program which he had watched. He reflected:
The other day I was watching a medical program on TV. A lady was suffering from sudden pain in her head. The CAT scan showed an unexplained coloured area in the brain. The lady was relieved and they couldn’t find a logical explanation for it. The lady said that she could feel the pain moving from her head through out, the tips of her finger. These sort of things don’t have a scientific explanation. The religious explanation, however, is that it was the demon and it got out. This is still not clear and has lots of contradictions. But I believe it is there.
151 Most participants believed in the presence of Jinn and sorcery because they are mentioned in the Qur’an. A small number talked about the possible harm which they do to humans, such as causing mental health problems. Most thought that their psychological problems were not related to Jinn or sorcery. While most previous studies of Muslim societies have indicated strong support for the attribution of mental health to spiritual elements, it is clear from this study that most participants did not attribute their mental health problems to Jinn or sorcery. This could be because of the increased awareness of mental health problems, as was identified in the analysis. Most who thought that there was no effect of Jinn and sorcery in their case linked this to their belief in Allah. The reading of the Qur’an and asking for Allah’s help were seen to be a protection from any possible effect of Jinn and sorcery. Those who did not believe in the effects of Jinn or sorcery still tended to identify themselves as practising Muslims. There was no influence of gender or educational level on the beliefs concerning the effect of Jinn or sorcery.
The Eye of Envy: Hassad
In the Qur’an and Hadith there is a mention of the negative effect of what is known as ‘envy eye’. It might be the cause of psychological and social problems. Al-Issa (2000e) describes envy as the desire by one person to have the grace of Allah removed from another person. It is when one person who has the influence to harm others. This could be through direct eye contact or through the spirit. Al-Issa (2000e), El-Islam (2000), Helman (2000) and Al-Subaie and Alhamad (2000) argue that the qualities that might attract the evil eye include achievement in study or work, beauty, intelligence or wealth. The eye would cause some psychological problems as a consequence. The evil eye usually comes from people who are jealous or envious (hasad) (Islam 1.11.06; Jamal 1985).
Ibn al-Qayyim (1900), an important scholar in Islamic philosophy, considers that the effect of the envious eye is not only through direct eye contact but also through the effect of the soul. Some who have envious eyes could be blind yet still might
152 affect others through their soul. Ahmed (1998) notes that some Muslim scholars discuss that there are two kinds of evil eyes: human and Jinn.
While envy is mentioned in the Qur’an, the effect of an envious eye is not directly mentioned. However there is a strong presence in the prophetic tradition about the evil eye causing psychological and social problems. In the Hadith, the Prophet recommends different treatment methods to get rid of the effect of the evil eye. Some preventive methods are also recommended by the Prophet.
The Prophet says:
The effect of the evil eyes is a fact (Sahih Bukhari v7 p. 636).
The Prophet also says:
The evil eye is real, and if anything were to overtake the divine decree (al- qadar) it would be the evil eye (Sahih Muslim p. 1192).
Importantly, envious people or individuals have no power without Allah’s will. Not every evil eye comes from jealousy, sometimes it arises from admiration. The admiration of the self, a close relative, or friend if not associated with the mentioning of Allah’s name or praying for blessing, might lead to the invoking of the evil eye (Ibn al-Qayyim 1900; Islam 2005). Ibn al-Qayyim (1900) explains that some people might be affected by their own evil eye.
In spite of the strong mention of the effect of evil eye, Jamal (1985) notes that some scholars argue that it has no effect and that these sorts of discussions do not match Allah’s justice. This view is taken by scholars who deny the effects of spiritual elements in the world.
153 It is clearly stated in the Qur’an that the envious eye is part of Allah’s will, and it only happens within the power of Allah:
Nothing happens to you except in accordance with God’s will (Qur’an 64:11).
Envious Eye: Perceptions of participants
Male and female participants talked about the possibility of the affects of the evil eye with less uncertainty. The attribution to this factor was one of the more common among the participants, regardless of their gender or level of education.
Some of the participants talked about the envyious eye as one of the important elements that had caused their mental health problems. Hannan, one of the female participants, talked generally about the effect of evil eye.:
The evil eye is a reality, and I myself believe in these sorts of things.
Some believed in the effect of hassad because it is mentioned in the Qur’an.
Jameel, one of the male participants who considered himself to be religious, talked about hassad:
Hassad is mentioned in the Qur’an. There was Envy from the time of the Prophet. That’s what makes me believe in that. It is mentioned in the Qur’an.’
Jameel further discussed the elements which created hassad. Envy is part of human nature, he claimed, and part of life and Allah’s will:
It is something real and present because of the class difference, in terms of the social and financial differences. It is mentioned in the Qur’an and the Prophet’s tradition. It is mentioned because it is there. It is the nature of life and how it is built. In life there is no equality among people. It is God‘s will for the human being. As a consequence this would lead to things like envy,
154 the envious eye. But for me I try to think logically about these sorts of things in isolation from the environment, life, and faith.
Nida, one of the female participants, talked about how her psychological problem was related to hassad. The hassad, in her opinion, might affect some people more than others. Some might be less privileged in life but still get envied. The vulnerability to being affected by an envious eye was part of human destiny.
This is considered a problem in our society. I mean of course everything is in God’s hand. There are many who have more money than we do, but they don’t have problems like us. It is our qadar in life, more problems. It is our destiny.
Ali told me how his case was related to envy by others, and explained some of the possible reasons which attracted their jealousy or admiration.
The evil eye is one of the most possible things. Because when I was at school I was very distinguished, even though I was studying in a disadvantaged school.
He further explained how the envious eye might have not arisen by direct contact with others, but in his case he might have been affected by people whom he had not even met.
Teachers used to constantly mention my name and talk about how well I did at school, being the top student. They still do that even though I graduated five years ago. People still talk about it. Teachers would say that to thousands of students. One of these thousands at least might have envied me. I mean that’s why I looked for Qur’anic healing. I was afraid it might be an envious eye.
Ali considered other features which contributed to his mental health problems. The envious eyes was considered a possible trigger which might have provoked other causations of the psychological problems. These might be easily recognised but the envious eyes was not.
155 Maybe the problem is originally because of the envious eye; I mean maybe these things are there but never caused me problems, but when someone envied me then these things led to my psychological problems. But the things happened because of hassad.
Hassad like Jinn or sorcery might be identified as the cause of the problem after reading the Qur’an. The Qur’an would reveal that there was an effect of hassad. The signs which indicate the effect of hassad vary, and it is the Sheikh who could decide the symptoms which indicate this. Ali explained how he was more inclined to think of envy as the main cause of his problems after reading the Qur’an.
It appeared and it was discovered from the reading of Qur’an. My body was shaking while the Qur’an was read on me. Practically, the evil eye is a reality.
Shakeera, one of the female participants, reflected on how the hassad changed her and her family’s life, and affected her psychological wellbeing. She talked about the subject of envy by others:
We used to have an excellent life; I mean every thing was okay at my home and with my children. Our neighbours used to envy me. Things changed at my home, and I got sick.
Nour, another female participant, gave an example of how she got sick after being exposed to what she thought was an envious eye:
I was visiting my mother and a relative was visiting there too. She sort of looked at me and I could see she was jealous. I think I was envied by her. The envy started to affect my head and chest.
Some considered the envious eye responsible for their coping with the problem. The envious eye might have been responsible for causing their problem to get worse, and not only for causing it in the first place:
While I was at my relative’s home she commented that I have a nice face without mentioning Allah’s name. My God, shortly after that I felt I am not
156 able to hold my foot when I was taking a taxi home. I wasn’t able to sleep at night. I was screaming. I treated that by reading the Qur’an for a whole week. Now thank God, I am better, but it is affecting my head and chest.
Mahmoud talked about the difficulties of deciding whether the problem was due to the envious eyes or to other causes. The other aspects were easier to recognize than the envious eyes:
I am able to recognize other causes such as personal things, hereditary factors, upbringing, and personal traits. It is not possible to recognize the envious eyes.
Some talked about the possibility of envy causing their mental health problem with hesitation:
I went once to a female Sheikh, who told me I was envied. I don’t know if she was telling me the truth or not.
While most participants talked about the effect of hassad, others were less certain about attributing the cause of their psychological problem to envious eyes. A small number of participants did not quite agree with the diagnosis of the Sheikh. These participants did not agree with the possible effect of any other spiritual factor on their mental health problems.
A number of male and female participants disregarded the possibility of envious eye because of how long they had suffered of their mental health problems. If it was caused by hassad, they claimed, it would have been healed by the reading of the Qur’an. Hannan reported:
It is possible that the envious eyes could sometimes cause you to feel sick or to have a headache, or for anything to happen to you. But in my case, no I do not. I mean I don’t feel I was envied because the problem has been going on for a long time.
157 A small number of participants talked about excluding the evil eye in their case, as they did not believe in it and its effect on mental health problems.
Hussain, one of the male participants, commented:
I don’t even believe in the evil eye or that sort of thing. I do not believe in these things.
As she excluded the effect of hassad on her case Suad, one of the female participants, reflected:
I don’t believe in these sorts of things at all. Even if I thought I was envied, I would use prayers to protect myself.
When discussing the possible causation of their mental health problems, more participants, regardless of their level of education, talked about the possibility of hassad. Hassad was mentioned as a general term, with or without mentioning the possible content of envy, or the traits which attracted the subject of hassad. More females talked about the possible effect of hassad than males. Participants talked about the effect of hassad regardless of their level of religiosity.
In summary, in this section I have given an overview of the themes which emerged from the reading of the Qur’an and the Hadith, and from the discussions with participants around Jinn, sorcery and hassad as possible causations of mental health problems. This secondary level of causation was discussed within the context of the relationship with Allah. While Jinn, sorcery and hassad are mentioned in the Qur’an and the Hadith, there is no clear indication of how they effect mental health problems. Most participants believed in their presence as they are mentioned in the Qur’an and the Hadith but not many considered Jinn or sorcery to have had an effect on their mental health problems. More talked about hassad as one of the possible causes of their problems. In the next section I will discuss the socio-political causes of mental health problems.
158 159
Section Three: Socio-political or physical causes
My focus in this section is on political, and social causations. I reflect on discussions I had with the participants around these issues. Social and political causes were frequently seen as reasons for mental health problems by participants. This concurs with what Al-Issa (2000) has indicated.
From reading the Qur’an and the Hadith I found that there is an emphasis on the responsibility of everyone to treat each other with kindness at various levels. These are the family level, the societal level, and the global level. Failing to achieve the balance in these levels will consequently create social and psychological problems including mental health problems. Mental health problems could be caused as a consequence of the wrongdoing of a whole society. Therefore mental health problems could be caused by family members, others in society, or by individuals not following Allah’s tradition (Qutb 1979; Ibn Kathir 1966).
Social and political causes within participants
From the discussions with participants it became clear that socio-political causations were important. While participants did not always relate the social and political, global causes directly to their religion, as they did in the basic attribution to the relationship with Allah or when they discussed the attribution of Jinn, hassad, or sorcery, they still indirectly related many of the social or political causes to religious concepts and contexts. The attribution of these aspects is still well placed within the context of Allah’s will and can more specifically be attributed to Allah.
Some of the participants based the cause of their mental health problems on other cultural contexts which might not be directly related to religion. Some related their
160 problems to society, relationships in the family, or political conflicts on a national or international level.
Social, familial level
Most of the participants talked about family problems, childhood experiences, stresses and pressures around them as the possible causes of their mental health problems. This is also asserted by Sulaiman, Bhugra and De Silva (2001).
Childhood experiences
Male and female participants mentioned frequently the possibility of their childhood upbringing affecting their psychological problems. The main points raised were strict rearing practices and the high expectations placed on them by family. These were seen as possible initiators of mental health problems. In most cases the style of upbringing was not directly discussed within the context of religion.
Mahmoud, is a practicing Muslim who described himself as a shy person, discussed how his strict childhood background contributed to his vulnerability and possibly caused his mental health problem. He talked about his parents with respect. This was possibly related to his religious beliefs, which emphasize kindness to parents (Qur’an 17:23). He talked with appreciation of his parents’ role despite of criticizing their strict approach.
I think there were some mistakes in the ways I was raised by my family. There was no abuse or violence, but strict education. I mean God bless them, they did their best. The mistakes were made without any bad intentions.
Firas, another male participant who identified himself as moderately religious, discussed the effect of his upbringing on his mental health with a less forgiving tone.
161 The other cause is that the family contributed to worsening the problem. They were focusing on the negative side and they were criticizing me with lots of things. I used to feel very disturbed. I didn’t used to eat well. I didn’t have a good appetite. This caused me psychological problem.
Some highlighted the role of a particular family member in provoking mental health problems. Relationships with fathers were the most highlighted experience in relation to the attribution of a mental health problem. A mother’s ignorance was also considered the cause of the problem by some of the participants.
Suad, a female participant, reflected on the possible role her mother played in her raising. She blamed the mother’s style of upbringing – but not without blessing her to indicate an appreciation of her role. The participant discussed a different style which she considered more appropriate, and which could have been more preventive of psychological problems.
My mother didn’t take notice. God forgive me for saying that. You know the older generation (God protect them) they weren’t like us now who observe our children. The mother is supposed to be aware of her children and she is supposed to take care of every small detail in their lives. My mother wasn’t like that. She didn’t notice me or my brother and sister. They didn’t used to notice what was going on with your life
Hannan, who presented herself as devout and practising Muslim, reflected on the differences among families in general in terms of the ways of raising children. She considered that extreme strictness with the children was a possible cause of psychological problems. She considered her harsh upbringing as a child as a possible cause of her mental health problem. A comparison was made between different styles of upbringing. Whatever the style was, the harsh dealing with children, which might be adopted by some religious families, was seen as a possible cause of psychological problems. She told me:
It depends on the family too. There are some families who are a bit liberated, sophisticated, let’s say educated. There are other families who practice more pressure; there are others who are extremely religious. If the family is strict this might cause psychological problems.
162 Some male and female participants described fathers as being strict and distant. More females talked about the relationship with their father as the possible trigger for their mental health problems. Jordanian families, like other Arabic families, are hierarchal. The father’s responsibility is to take care of the family and to ensure the raising of the children (Barakat 1993). Some of the male and female participants in the research described their father as being strict and domineering.
The strictness of their father was seen to be the possible cause of mental health problems by female participants, who probably are exposed to more pressure within a patriarchal society. Hanan, who had talked about different styles of upbringing, stated that her relationship with her father was possibly a cause of her anxiety:
My mental health problem might be because my father used to have a very bad temper. We used to feel terrified of making any mistake. We used to be afraid of his punishment. It caused my fear, and complicated my life.
Hannan also talked about the differences in the treatment of females and males within the family. Fathers are harder on daughters than sons. This was seen as part of the social order or tradition, rather than being a household problem. It is part of a culture which privileges male over female. This behaviour was seen as a cause of mental health problems:
My psychological problem is caused by strict dealing with us girls from my father. There is possibly no equality in dealing between boys and girls. I mean the boy is able to speak up, allowed to go out, and to express his feelings. The boy would do whatever he wants. No, the girls are not the same. There is always more pressure on girls in our society.
Salma, one of the female participants, commented on her father’s strict dealing with the girls and his permissive behaviour with the boys in an irritated tone:
163 My father used to be so hard on us girls and he would think that males could do whatever they want and it is okay in an exaggerating way. He was too strict on us girls. All our society is like that.
She further reflected that the behaviour of her father did not follow religious teaching. His behaviour was seen as part of the society’s traditions, and not in accordance with Islam:
It is not because he is religious. I feel he is a hypocrite. He just wants to look good in front of his relatives. If he was really religious he would not agree with my brother’s behaviour.
Male participants talked about childhood trauma as being one of the causes of their mental health problems.
Incidents in life such as the death of a parent are all Qadar or fate. In spite of the pain behind them, these life incidents have wisdom within. Most of the discussions around the possible role of the family in the causing of the psychological problem were associated with an apologetic tone and religious expressions which indicated a blessing for parents or an appreciation of their role. This was especially so for participants who identified themselves as practising Muslims: appreciation of parents is considered important in Islam.
The tendency to attribute problems to childhood experience was probably due to the influence of increased awareness and educational programs in the media which discuss modern ways of raising children and the importance of childhood upbringing.
Burhan, one of the male participants, discussed how the loss of his parents was a possible cause for his mental health problem.
164 Maybe one of the causes of my psychological problem was the death of my mother when I was young. I was 8 or 9 years old. I lost my father when I was in high school.
Jameel, a male participant, told a story indicating that a possible cause of his mental health problem was losing his father at a young age:
On our way to Amman we had an accident, in Jerusalem, and an Israeli army car hit us. My father died instantly as a result of the accident.
Marital relationship problems
Marriage problems were seen to be a major cause of psychological problems for female participants. This is asserted by El-Islam (1998) and Sulaiman (2001), who argue that women often become psychologically affected because they are not able to meet the role expected of them. Women, for example, that do not have the chance to marry, or are not able to have children, are insecure in their marriage, or are threatened with loosing their fertility due to health problems are more prone to mental health problems. In this study all the married male participants indicated that they had good relationships with their wives.
Some of the female participants talked about being abused as the cause of their mental health problems. When there was an abusive relationship from a previous marriage or current marital relationship, the abuse was seen as a central trigger for mental health problems. There were discussions about how they were fulfilling the role of a Muslim wife in the marital relationship, yet husbands were considered abusive and not fulfilling their roles, rarley treating their wives with care and respect. While the study of Haj-Yahia (2002) shows that women experiencing domestic violence justify the abuse, this study found that women not only rejected the behaviour, but considered the abuse as an act against religion, and a major cause of their psychological problems.
165 Nour, a female participant who had been divorced for a couple of years and considered her mental health problem to have been generated by her abusive relationship, reported:
He used to abuse and humiliate me. He was controlling. I swear I treated him like I was supposed to in the Islamic traditions. I tried to please him in every possible way.
Suad, discussed the possibility of the correlation between her mental health problem and the physical and emotional abuse of her husband. She considered his behaviour as being against how religion prescribes he should treat her. The religious expressions were to help her to cope with the problem, and also to express that she was patient and tolerant of Allah’s will:
(Lowering her voice and talking hesitantly) Maybe it is because of the marriage life. It was very hard at the start. My husband was too cruel with me (rolling the sleeve of her clothes to show me the scars of the physical abuse). He used to always hit me. He has no fear of Allah. Allah Yaghfer le [God forgive me].
She further reflected on her feelings of shame and being degraded because others around her knew about the abuse. This would consequently lower her status within the community.
What hurt me and affects my self-esteem is that everyone knew about my husband hitting me and verbally abusing me. I started to feel that I did not have status. I mean people would consider I am not respected or regarded enough by my husband.
Rania told me of her ex-husband’s abusive behaviour which was related to alcoholism:
To see my husband having alcohol every night, and getting drunk, was a problem for me. I never had seen something like that in my family. It was a shock to me.
166 She further talked about the effect of the problem of abuse using western-style expressions. At the same time, she analysed the cause of her mental health problem within a cultural context in which the husband is supposed to treat his wife with respect and kindness, and has an obligation to support his wife and children financially.
I changed so many things in my life just to please him. I wasn’t myself any more. I used to walk with a strange different personality just to please him. I used to be scared of him. He used to hit me even when I was pregnant. He didn’t spend money on the home. He didn’t Itaqi (safeguard Allah’s role) in his dealing with us. It was a very hard life.
Some female participants, who expressed that they were happy in their marriage, said that the relationship with their in-laws was the cause of their mental health problem. There is a strong presence and influence of in-laws in the Jordanian family, which is based on a collective relationship. The nuclear family has in most cases a strong connection with the extended family (Barakat 1993).
Maryam considered the way her in-laws were treating her as an essential cause of her psychological problems. Because of her religiosity, she was trying to suppress her anger towards her in-laws, who were elderly people. She thought that they were not treating her fairly and were not safeguarding Allah in their dealings with her.
You could say my in-laws are very hard. I didn’t feel comfortable living with them. I am a kind of a person who respects my uncle and auntie. I can’t argue with them. I used to repress all my feelings. I am always keeping quiet; I never talk back to them. They do not have taqwa [piety] .
Divorce was one of the social problems which was discussed as a possible cause of mental health problems. The difficulty in dealing with divorce is partly due to the stigma associated with divorce within particular cultures. Although divorce is allowed in the Islamic tradition (Qutb 1979) within cultural groups it is seen to be highly stigmatized (Al-Krenawi & Graham 1998; Barakat 2006). The discussion of
167 female participants was within the context of social tradition and no link to religion was made.
Nour outlined the direct influence of her divorce on her mental health problem. Her feelings of loneliness and the fear of stigma contributed to her psychological problem. One of her difficulties was the fear of not getting another chance of being married because of her divorce:
I went through a very bad state after the divorce. I said to myself, who would ever think of marrying me again. I am not young any more and also divorced.
Even when the family supports a women in getting a divorce, the fear of getting the divorce and the stigma associated with it is strongly present. Rania reflected on the difficulties in making the decision:
My family used to ask me to leave him. I used to tell them I couldn’t because of my daughters. I was so scared. I stayed until I reached the point where I couldn’t take his abusive behaviour anymore. I was worried about how I was going to take the step of getting the divorce. I needed a lot of strength.
The death of a husband was seen as a major trigger of psychological problems for a couple of the female participants. Nida, who identified herself as religious, reported how the death of her husband was a shock for her. She considered it as part of her destiny and trial. It was directly related to her relationship with Allah.
When my husband died I was shocked. I mean we hadn’t been married for more than 3 years. (Crying) Qadar. This is when I started to experience the psychological problems.
She further reflected on the difficulties associated with being a widow, which contributed further to her mental health problem. Some of these were related to conflict about the inheritance after the death of her husband.
168 Then my husband’s family took me to court. It is still going on (crying). People in our society do take advantage of the widow. Unfortunately, this is our society’s nature. Many have no fear of Allah.
Shakeera considered the loss of her husband as the major trigger for her depression. She considered the death of her husband as being Allah’s will, Qadar, or trial. She expressed her commitment to accepting her destiny.
The death of my husband affected me so much. In sha Allah [Thank God for everything]. I am patient.
General Stress
Some talked about their mental health problem as being the consequence of too much hard work, stress, frustration, or because they did not have balance in their lives. There were some elements of the problem that were analysed in western manners, where problems are seen to be caused by not voicing feelings and not expressing distress. Having balance in life is encouraged in Islam. The Prophet says in the Hadith:
There is share for your eyes, share for your own self, share for your family (Sahih Muslim p. 564).
This balance is important in achieving mental health. Overwhelming the self with so many worries and so much work was seen by some of the participants as the cause of their mental health problems. Although discussion of participants about stress as the cause of their mental health problems has its roots in religion, it was mostly introduced and expressed in a modern, contemporary style.
Fouad, one of the male participants who considered himself religious, talked about a demanding lifestyle as one of the sources of his psychological problems. He discussed the cause of the problem as not releasing his frustration and the repression of his feelings:
169 My problem is I do not vent my feelings. When I am not feeling well I used to study harder. I didn’t used to cry or to vent my feelings. The situation I am suffering from is because the problems accumulated over the years.
Baheera, a female participant who considered herself religious, analysed the cause of her problem as an accumulated stress:
I mean in my case the stress was the main reason which triggered the psychological problems. I was a young mother, and I used to take care of my children. We used to live in Kuwait and I didn’t have the support of my family. I used to be very exhausted. All that accumulated, and caused me the problem.
She then explained how she was exposed to more stress when she went to the pilgrimage to Mecca. She explained how she was adding more pressure on herself by travelling to Mecca while being exhausted already by her family chores. She discussed the cause with expressions of guilt, as she associated her psychological problem with the practising of some of her religion duties. Comments by others around her contributed to her feelings of guilt by pointing out that she was not supposed to associate her psychological problems with going to Mecca.
[In] 1984 I went to Mecca for a pilgrimage. (I mean some people told me it is not appropriate to connect your illness with the pilgrimage), but I think what happened with me was a result of stress. I was young. I was 30 years old. Back then I had the responsibilities of 5 young children. I went from Kuwait to Mecca by bus. When I came back from Mecca it was the start of the schooling. All my children were young. I think, I think, I don’t know, I think it was a tiredness, fatigue. I didn’t feel well after that.
Not meeting the high expectations in relation to academic performance was a major trigger for some young male university students. Ali, one of the male participants, explained that he overwhelmed himself by setting high standards. The pressure to do better is also emphasized by families (Sulaiman, Bhugra, De Silva 2001):
The cause of my problem is my studies. I know other people might be accepting just to pass the exam. For me I am not looking for just passing the exams, I am looking for something more.
170 He further added:
The problem started when my family pressured me to study medicine. I studied for 3 years then I transferred myself to study engineering. You see, I was the top student in the first year of my studies, but then when I finished year one (Glory to God) I started to deteriorate. I mean I stopped attending lectures.
Some considered the problem to be caused by disappointments in life. The word Ihbat, which means frustration, was a common pscyhological theme used by participants when they talked about the causes of their problems or when they described their mental health problems. Part of the frustration was not being able to fulfil their dreams or to support other family members. The problem was discussed in a modern western manner in some cases.
Amal, one of the young female participants who considered herself religious, talked about her dissatisfaction with life, as she had just graduated and was having difficulties finding employment. Unemployment is one of the social problems in Jordan, especially among youth and recent graduates (Miles 2002). A growing number of women in Jordan play an important part in sharing the responsibility in the family (Lowrance 1998).
The participant reflected on this problem, as she considered that she was not able to provide support for her family:
The problem is caused by my frustration in life. I have so many things that I want to have. I have so many ambitions. I wish for so many things. I wish I could continue my university studies, to have a car, to help my parents, and my sisters and brothers, to live in a nice home, to get my family whatever they want. But I can’t. I think I am frustrated.
Poverty and unemployment were seen as contributors to mental health problems for young participants. Firas, one of the male participants, talked about his frustration in finding employment after he had graduated as an engineer:
171 Many young people in the country are really tired. There is no employment and every thing is so expensive.
He made a comparison between the lives of people in western countries and those of Jordanians. He commented about the reason he was trying to migrate to a western country:
I want to have a good job, any reasonable job. But here in this country my chances in getting job as a chemical engineer are not very high. There are better opportunities in western countries. They appreciate the engineer more than they do here.
Participants also talked about various types of stresses such as being away from family members, or high expectations, or caring for someone with a mental illness.
Maryam, one of the female participants talked about being away from family as a one of the contributors to her psychological problems.
You know. Being away from my family makes it hard for me to have that support. They are still in Iraq. I miss them so much. It was very hard for me to leave them behind.
Caring for individuals with mental health problems was seen by some as a strong contributor to mental health problems (Rooney, Wright, O'Neil 2006; Young, Bailey, Rycroft 2004). Caring for the relatives in need is considered an obligation for Muslims (Sahih Muslim p. 418). Alwan, one of the male participants, also reported that the burden of having a relative with schizophrenia was the main stressful events which led to the psychological problem:
Well, my brother caused my psychological problem. I have a brother who has schizophrenia; this brother caused us trouble all along. We have tried everything to help him, but he likes to cause us trouble. I used to be the main carer for him and I was mainly the most companionate one with him. But he is a sort of a manipulative person who abuses the ones who are kind to him.
172 Another female participant considered that caring for her son who was suffering from schizophrenia was one of the contributions for her depression. She expressed her acceptance of Allah’s will in spite of the difficulties, indicating her submission to what she considered Allah’s will.
My son who has a mental illness, schizophrenia, was admitted to the hospital twice (Thank God for everything). All that caused me a strong depression.
Political Attribution
While female participants talked more about social problems as the cause of their mental health problems, more male participants considered political matters as one of the main contributors to the cause of their mental health problems. This was especially so among male participants from Palestinian backgrounds. People from Palestine have experienced trauma related to long-running conflict and war. Literature indicates the strong influence of these sorts of unstable, brutal circumstances in originating mental health problems (Al-Krenawi 2005; Abdulrahim 1992). The participants talked about these experiences as part of the Qadar and trial of human beings: they were all within the context of Allah’s will.
From the discussions of participants, the refugee experience was one theme which emerged in relation to the causation of mental health problems,. Most of the participants were from a Palestinian background. Some came to Jordan as refugees in 1948 or 1967. Some of the male and female participants used to live in Kuwait and moved to Jordan in 1990 after the Gulf crisis. Most of the Palestinian participants still have connections with families in the West Bank.
The conflicts and political problems happening in Israel and the West Bank have a strong affect on these people. Going through wars or trauma is one major causes of their mental health problems (Halabi 2005). Jameel, one of the male participants who came to Jordan as a refugee in 1967 (when Israel occupied the West Bank), talked about the loss of stability and the dramatic change as a result of leaving his
173 village. The past experience of being a refugee was considered a major cause of his depression and anxiety. He described his life before having to leave and the trauma associated with leaving, and talked about his grief and loss from his early childhood:
I used to have a nice life in the West Bank. I was 9 years of age when everything changed. I was forced to go out. I hated that. This is one of the basic things to my deep anxiety. I mean it is one of the hardest things that could happen to a child in such a young age. I mean to leave your land, friends, and family. I used to take the bread from the taboun (traditional oven) and go to the fruit garden and pick up grapes, and figs before going to school. When we came back from school we used to play with the ball. Everything changed all of a sudden after my father was killed by an Israel army car. I lost my homeland, my family, and my friends all at once. Then we came to Amman. This history still has an effect on me.
He further talked about collective social and political problems which contributed to his psychological problems. He discussed how the experience of being a refugee created a sense of awareness of the prejudice and inequality in the society. The political problems highlighted some social problems.These political problems were not only seen within society level, but on a global level.
The cause of my psychological problem is an accumulative one. It started in the 1967. It does grow with age and with more awareness. I mean age and the awareness of the things going on in the world today. All these things are building to it. It is hard for me to explain in details how the anxiety started. For example, as a child I started to be aware of the class division in the social life and society. I started to be aware of the injustice in the world. I realized the destiny of some people to suffer, because others do not care enough. This is a point of start for the anxiety. You see from the early childhood I felt of the power of the clannishness, and the class. So imagine how many stories and incidents in life have occurred with age and awareness.
Hussain, a Palestinian male participant whose family came as refugees in 1967, and who indicated that he was not a practising Muslim, discussed the cause of his problem in relation to the global political situation in the world. The prejudice of western countries towards the rest of the world, especially the Muslim countries, was seen as the cause of his depression. There was a sense of frustration among
174 individuals from Palestinian participants as they felt that they had been denied many of their human rights.
The effect of racism on mental health of individuals with mental health problems is also discussed in the literature (Swartz, 1998). One of the basic discussions is found in the writings of Fanon, who was a psychiatrist in Africa. Fanon addresses the influence of racism on the perception of identity in African societies, and on various aspects of mental health (Fanon & Philcox 2004); Swartz 1998).
Hussain reflected this notion in his discussion:
I don’t like the regime in the world. It is full of injustice. I mean a powerful country like America is targeting people who have no equivalent power. There is no fair dealing, especially for Palestinians.
Participants who started living in Jordan in 1990 after the Gulf Crisis indicated a strong link between their mental health problems and the trauma associated withit. Studies have indicated a significant increase in psychological problems within Jordanian returnees from Kuwait during the first Gulf War (Al-Krenawi 2005).
Jameel talked about the grief of having to leave Kuwait after the crisis in the Gulf. This experience of being a refugee as a child was re-lived when they left because of the war. This highlighted his sense of uncertainty and injustice in the world. The dramatic changes in his life added to his difficulties and consequently led to his problem:
I went to live in Kuwait when I was 18 years old, but we had to leave again after the Gulf crisis. You know the crisis before the problems, we used to live the best life. We adjusted very well. I married over there and I had my own business, and good relationships. All that collapsed all of a sudden. Then we started the journey back to Amman (laughing) in the 1990. All these aspects are part of my Qadar. I started to experience anxiety soon after we left Kuwait.
175 Burhan, a Jordanian male participant on a low income who identified himself as moderately religious, talked about poverty as a strong contributor to the cause of his psychological problems. He linked the cause of psychological problems in society with the poor quality of life, shortage of resources, and insecurity. He considered the lack of applying the Qur’an as another problems:
The cause of my problem might be due to pressure in life. Let us say the problem is the poverty. There are some basic needs for human beings. They need to feel safe. Most psychiatrist illnesses, as I see, are caused by pressure in life. The reason behind mental health problems is poverty. Understanding the Qur’an and following it is what we need to do in order to understand these things.
Physical and Hereditary Factors
Many discussed that the causes of their psychological problems were physical, that is, their condition was related to some physical illnesses. The physical problem was seen as the initial cause of their psycho-social problems.
Burhan told me that one of the main causes of his problem was the physical problems which caused his mental health problems:
I also suffer from a problem with my blood pressure. All my family suffers from blood pressure problem; I mean my father, my mother, and my brother, used to have pressure. The problem and the psychological problems are sort of a vicious circle. The pressure is affecting the psychological problem and the psychological problem is affecting the pressure, I am always thinking about the problem.
Some considered physical symptoms a reason in addition to other reasons which caused their mental health problems. Fouad said:
I think there is an explanation. At the end there is no line between the physical side and the human side of the human being. Practically at the end everything is motkaml [comprehensive].
176 Not many participants talked about their mental health problem as being caused by hereditary factors. For some who mentioned hereditary issues, these were linked to other causes or the discussion was begun to deny any effect of hereditary factors in mental health problems.
Mahmoud, one of the male participants talked about the possibility of hereditary in addition to other causes.
(Talking enthusiastically) Maybe the reason has to do with hereditary … honestly I think my situation has to do with hereditary. Not the only reason as I said ,maybe there is more than one cause. I think in my case the hereditary in addition to my personal characteristics.
Maryam, one of the female participants, talked about her grandmother who had similar symptoms to her own. The discussion was around different possible causes for her grandmother’s mental health problem. This was in order to exclude the possibility of hereditary causes in her case. Maryam, who had difficulties in her relationship with her in-laws, avoided the possibility of hereditary causes. This was because of the worry that these might worsen the situation with her in-laws, who might worry that their grandchildren might inherit their mother’s psychological problem.
My grandmother used to have an obsession too. I mean my grandmother onmy mother’s side. But it is not hereditary. It was because my grandfather was very hard on her. My father in-law keeps telling me that it is hereditary and he is worried about the children.
Many participants attributed the cause of mental health problems to family relationships as well as to political factors. While more females talked about social causes, more males talked about political causes. The intensity of these problems meant they took priority in being attributed as the cause of the mental health problems.
177 Summary
I was interested in understanding to what or to whom the participants in my research attributed the cause of their mental health problems, and how the causation of mental health problems is conceptualized in the Qur’an and the Hadith. It was clear from the analysis that there is generally more than one reason given for peoples’ mental health problems. However, in this research it was also clear that these attributions were often interrelated.
What is most apparent is the overarching attribution of mental health problems to Allah, who is considered all-powerful, and so any problem experienced by people who follow his ways is seen to be due to his will. Although many of the causes were seen to be related directly to the relationship with Allah (Allah decides it this way), others were directed to a secondary attribution and seen to be due to the ‘invisible power of the spirit’. However, all other causes, including socio-political and familial relationship were seen as secondary representations of Allah’s will. In the next chapter I will address the concept of help-seeking – a major theme which emerged from analysis of participants’ interviews and from the analysis of the Qur’an and the Hadith.
178 CHAPTER SEVEN
THE HELP-SEEKING JOURNEY Introduction
The sections in this chapter address the subject of help-seeking. I reflect on my conversations with participants and how they described their help-seeking efforts, and how help-seeking is conceptualized in the Qur’an and the Islamic prophetic tradition.
When talking about the concept of help-seeking, Pescosolido, Boyer, Lubell (1999) observe that it is a concept which has various other labels, such as decision- making, illness behaviour and service use. Agbayani-Siewert, Takeuchi, and Pangan (1999) describe help-seeking as a social process whereby individuals make decisions about their needed support whether this is from formal mental health organizations or from informal cultural networking. Idler and George (1998) argue that healing is the main goal of seeking help. They further assert that healing in the religious sense means wholeness or the restoration of a broken body, mind, or spirit. Aneshensel and Phelan (1999) note that social science seeks to understand the way people react when suffering from mental health problems. They further argue that in spite of the need to understand the process which leads to the act of help-seeking, there is also a need to better understanding the cultural and social elements underly the help-seeking process as well as the medical organizational elements that.
Many scholars emphasize the importance of exploring the help-seeking process for individuals with mental health problems, in order to understand their perceptions about their psychological problems and their ways of coping (Al-Krenawi 1999b; Aloud 2004; Ayalon & Young 2005; Kirmayer & Young 1998; Townes 2004; Yi & Tidwell 2005; Youssef & Deane 2006; Razali & Najib 2000). Edman and Koon
179 (2000), Kirmayer, Young and Robbins (1994) and Williams and Healy (2001) argue that help-seeking provides mental health professionals with an insight into the perceptions of causation of mental health problems among individuals with mental health problems. Chadda et al. (2001) also assert that help-seeking is highly influenced by how people attribute causation of mental health problems. They further assert that individuals who attributed their mental health problems to supernatural powers are more likely to visit traditional healers for help, while others who attribute their mental health problems to natural, biomedical causes tend to access medical services.
Many scholars talk about the importance of social influences on the help-seeking process (Aneshensel 1999; Chadda et al. 2001; Aloud 2004; Ayalon & Young 2005; Corbett 1999; Youssef & Deane 2006). Aneshensel (1999) asserts that the treatment for mental health problems most of the time is initiated by family or professionals. Pescosolido, Boyer and Lubell (1999) argue that various studies have demonstrated that people with mental health problems access mental health services only after they are pushed to do so by relatives or friends. Mulatu (1999) and Budman, Lipson and Meleis (1992) make the same point and note that the family generally makes an effort to seek traditional or medical services when the problem can no longer be controlled within the home environment. They suggest that in the case of mental health problems persisting, the family seeks traditional healing, and that access of medical services is usually the last resort after all other traditional recourses have been exhausted. Ng (1997) argues that mental health services in some developing countries are stigmatized and do not meet the needs of individuals with mental health problems. As a consequence people tend to turn to family, friends, and traditional healing, rather than accessing psychiatric services.
Lefley, Sandoval and Charles (1998) note the contradictory attitudes among mental health professionals towards interventions such traditional healing. They argue that many mental health professionals perceive traditional healing as uncivilized and unsophisticated and think that it collides with the scientific medical system,
180 without paying attention to the significance of traditional healing within different societies. They further note that there are other mental health professionals who might consider the system as a complementary tradition that contributes to the improvement of the mental health state of individuals burdened with emotional distress. Fernando (2002) also asserts that there is growing appreciation of traditional healing among mental health professionals. The need to recognize the help-seeking process is emphasized by contemporary scholars who note that there is an increased tendency towards combining more than one approach when dealing with mental health problems, particularly in non-western societies (Edman & Koon 2000; Mubbashar 2000; Ayalon & Young 2005; Razali & Najib 2000).
In this chapter the help-seeking process will be addressed in two major sections. The first section will explore themes around the strengthening of the spiritual relationship with Allah as an underlying concept of the help-seeking journey. In this section I address the highly individual and confidential aspects of help-seeking between the creator and the created. The second section will address the practical aspects related to help-seeking. Four themes emerged as core elements of help- seeking in relation to these practicalities. Firstly, practice is associated with religious rituals, secondly, the accessing of professional help, thirdly, the accessing of traditional healing, and fourthly, the utilizing of social support. In the discussion I reflect on how perceptions about help-seeking are both directly and indirectly linked to the teaching of the Qur’an and the Hadith.
181 SECTION ONE
182
Keeping the relationship with God: Healing in Allah’s will
Strengthening the relationship with Allah is considered the basic element which underlies the help-seeking process. In the previous chapter, the relationship with Allah was considered the main context for understanding the causations of mental health problems in the Qur’an and the Hadith, and was also strongly reflected in the conversations with participants. This relationship with Allah is considered again in this chapter as the main component which needs underlining in the help- seeking journey. This was evident from the exploring of the Qur’an and the Hadith and from the discussions with participants. These principles permeate the entire healing process.
The fundamental value which contextualises the relationship with Allah is the belief that the healing of any illness or disorder is Allah’s will. Healing in this sense, like the causes of illness itself, is always from Allah. Individuals are to seek help but the healing is beyond human reach. It is Allah’s will. This concept is stressed in many places in the Qur’an and within the prophetic traditions. For example the the Qur’an says:
And when I am ill it is He who cures me (Qur’an 26:80).
If God touches thee with an affliction, no one can remove it but He (Qur’an 6:17).
The name of Allah as the protector and helper is also mentioned frequently in the Qur’an.
And He is the Protector, Worthy of all Praise (Qur’an 42: 28).
183 Having trust in Allah is the essence of the relationship with him. It is the precondition for the help seeking journey: this is also reflected in the following verses in the Qur’an:
God is the protector of those who have faith (Qur’an 2:257).
Or:
And on God let the believers put their trust (Qur’an 3:159).
In the seeking of help individuals need to ask only Allah for healing or for greater ability to cope with problems. Any other help or seeking for support is secondary to the main help which is from Allah. Any other help is just an instrument for Allah’s will. The Qur’an says:
And invoke not besides Allah any such that will neither profit you nor harm you (Qur’an 10: 106).
Healing is in Allah’s hands. Human beings are not able to grant healing to individuals. If healing is reached with the help of any human being, the healing is not because of the human being, but because of Allah’s will. This basic belief underlies the seeking for healing. Allah says :
And when I am ill, it is He Who cures me ( Quran: 26:80)
The help-seeking journey: Basic principles
It is clear from the two texts that the belief that healing, like illness, comes from and is found in Allah does not mean people should stop looking for help. Seeking help is part of the obligation of a Muslim when faced with problems such as mental health issues. Ahmed (1998) asserts that in Islamic beliefs there is an emphasis on
184 the importance of looking for scientific treatment for problems related to health as part of the responsibility of Muslims.
The Prophet assured his followers that there is a cause for every sickness. The Prophet also constantly encouraged Muslims to seek appropriate treatment (Kinzie 2000; Ahmed, 1998) and to integrate medicine and physical treatment with psychological religious healing (Kinzie 2000). If the cure is not found, there is a possibility and hope that it will be found in the future; there is a belief that there is a chance that human scientists will be directed by Allah to find a treatment (Ahmed 1998). Many Muslim scholars talk about this belief as a part of the dualist philosophy in Islam, as mentioned in the prophetic traditions, namly that there is always medicine and healing for every illness and problem (Al-Ansari et al. 1989; Qutb 1979; Al Khayat 1997). This is clearly stated in the prophetic traditions:
There is no disease that Allah has sent down except that He also has sent down its treatment (Sahih Bukhari v 7 p. 326).
While reaching out for treatment, individuals are not to feel guilty or bad if they do not achieve healing. It is a well-recognized notion in Islamic philosophy that while humans need to try to deal with their problem, it is beyond their human reach, as every thing is in Allah’s hands (Qutb 1979). In the prophetic tradition there is a mention of an incident when the followers asked the Prophet about their obligation in relation to dealing with health problems and help-seeking. The Prophet told them that while they have an obligation to seek help, the consequences of the journey and the cure by any intervention is within Allah’s will.
When followers asked the Prophet ‘Do our supplication, medication and methods of prevention prevent anything that God has willed?’ The answer of the Prophet was there ‘They are also part of God’s will’ (cited in (Al Khayat 1997, p. 9).
On the other hand, not looking for help is considered by Muslim scholars such as Qutb (1979) and Ibn Kathir (1966) to be a sin as it exposes the self to further harm.
185 The abuse of one’s health or exposing the self to any danger is something forbidden and sinful. This concept is identified in the Qur’an in the following verse:
And do not be cast into ruin by your own hands (Qur’an 2:195).
The seeking of medical treatment is encouraged by Islamic tradition and this treatment should be sought from any one who acquires the scientific knowledge or can provide support, regardless of their own religious or spiritual beliefs. The Prophet Muhammad explained to his followers
There is no harm of any treatment as long as it is beneficial to human being. (Sahih Bukhari vol. 7 p. 362).
186 The essence of the relationship
In this research it became clear that help-seeking approaches in Islam are based on a few fundamental principles and values. These values are the fundamental spiritual essentials which constitute the relationship with Allah while searching for healing. It is the underlying essentials which are supposed to inspire the search for healing. The following are the main components in the healing journey:
• taqwa (piety, safeguarding Allah’s commands) • tawba (repentance) • tawkul (reliance), keeping balance • saber (patience) • rida (contentment). Each is part of the main Islamic doctrine and interconnected with the belief that everything is Allah’s will. All these are prerequisites for the journey to seek help. Taqwa: submission to Allah
Taqwa or God consciousness is considered to be by far the most important factor in the relationship with Allah (Ibn Kathir 1966; Qutb 1979);(Ansari 2002). Scholars such as Ibn Kathir (1966) and Qutb (1979) describe taqwa as the constant awareness of God’s presence and reminding one’s self of the responsibility to obey him. It is considered the context which holds together all other aspects in relation to healing. In exploring the Qur’an and the Hadith I found that taqwa is the fundamental aspect in the relationship with Allah. It is the only way for the believer to overcome difficulties in life. The essence of taqwa is that Allah is the source of everything and anything that affects a human being, whether this is a good thing or a bad thing. The difficulties in life such as psychological problems will always be followed by easier circumstances. The following of Allah’s commands is the way to overcome problems such as mental health problems. Taqwa is always associated with hope and prosperity. Trust in Allah and the
187 safeguarding of his commands will consequently result in achieving goals and relieving distress.
And for those who fear Allah, He (ever) prepares a way out, And will provide for him from (a quarter) whence he hath no expectation (Qur’an 65:2,3).
Taqwa and the safeguarding of Allah’s commands will also be associated with the increase of wisdom. Individuals will be able to have the ability to chose the right act which will help them to overcome their problems. Problems, such as thinking patterns which might affect their feelings and affect them reaching happiness, will all be controlled by achieving wisdom, and by safeguarding the relationship with Allah. Taqwa, in this sense will positively influence the thinking process:
O ye who believe! if ye keep your duty to Allah, He will give you discrimination ( between right and wrong) and will rid you of your evil thoughts and deeds, and will forgive you Allah is of infinite bounty (Qur’an 8:29).
Taqwa and submission to Allah will provide strength for individuals so they can deal effectively with problems in life such as mental health problems:
Allah says ‘If you help Allah, He will help you and will make your foot hold firm’ (Qur’an 47:7).
Tawba: repentance, returning to Allah
Tawba (repentance, asking for Allah’s forgiveness) means, as Muslim scholars such as Ibn Kathir (1966) and Qutb (1979) assert, the genuine commitment to not repeating mistakes and committing sins. Ahmed (1998) and Husain (1998) also note that if individuals attribute the cause of their mental health problem to punishment for wrongdoing, forgiveness will be granted if they ask for it. In Islamic tradition every bad deed is forgiven if the human being asks for forgiveness
188 and is committed to change (Ahmed 1998; Husain 1998). I found that there is an acknowledgment in Islamic tradition that regret and feelings of guilt may lead to a psychological state in which people become affected by some psychological problems. Learning about forgiveness, as it is indicated in Qur’an and the Hadith is presented as a way of coping with these feelings. This is especially so in cases where individuals have guilt feelings which are associated with committing something against religious commands, and if they feel they are not deserving of good deeds. In the Qur’an believers are ordered to be easy on the self as there is a space where these misdeeds are forgiven:
Say: ‘O my servants who have transgressed against their souls! Despair not of the Mercy of Allah’: for Allah forgives all sins: for He is oft-forgiving, Most Merciful’ (Qur’an 39:53).
Giving up hope is introduced in Islamic tradition as not an act of a believer. The feeling of hope on the other hand is a sign of a strong relationship with Allah and it is based on the belief that Allah will respond to people when they ask for help. This is clarified in the Qur’an in the following verse:
And never give up hope of God’s soothing Mercy: truly no one despairs of God’s soothing Mercy, except those who have no faith (Qur’an 12:87).
Tawba is the way to get Allah’s help. The Qur’an urges Muslims to continually ask for tawba:
ask forgiveness from your Lord; for he is Oft-forgiving (Qur’an 71:10).
Tawba is considered in the Qur’an to be an essential elements for human beings to succeed in their help-seeking.
And turn unto Allah together, O believers, in order that ye may succeed (Qur’an 24:31).
189 Tawakul: reliance on Allah
Tawakul (reliance) means total confidence in God as indicated by Muslim scholars such as Ibn Kathir (1966) and Qutb (1979). I found this concept to be highly important in the help-seeking process. While individuals are encouraged to look for solutions and to improve their lives, the results are not in the hands of humans. They are in the hands of Allah. Tawakul, as these Muslim scholars explain means the acknowledgement of human beings’ limitations. Humans have certain boundaries which cannot be crossed. Disorder and healing, as Rahman (1998) argues, are from Allah. When, in this life, a person with mental health problems believes in this and trusts Allah as the source of everything, then a huge burden is supposedly lifted from his or her back, as he or she depends on Allah. The Qur’an says:
And on Allah let all men of faith put their trust (Qur’an 14: 11).
Say: ‘Sufficient Is God for me! in him trust those who put their trust.’ (Qur’an 39: 38).
Tawakul, like tawba, is also associated with holding on to the hope that Allah will definitely make things easier for individuals who put their trust in Him.
And never give up hope of God’s soothing Mercy: truly no one despairs of God’s soothing Mercy, except those who have no faith. (Qur’an 12: 87).
And He provides for him from (sources) he never could imagine. And if any one puts his trust in God, sufficient is (God) for him. For God will surely accomplish His purpose verily, for God appointed a due proportion (Qur’an 65:3).
Keeping balance
I found the concept of keeping balance in life a crucial aspect in coping within Islamic faith. It is about not ignoring one part at the expense of another. It is about
190 taking care of the human and everyday needs of the lives of individuals and not omitting or overlooking the spiritual needs. Ansari (2002) notes that the concept of nafs (self, or living entity), which indicates the foundation of a human being is considered, in Islamic philosophy, to be a mixture of the biological, the psychological and the spiritual. All these parts need to be nurtured. This concept is stressed in many occasions in the Qur’an and the Hadith, where there is an emphasis on maintaining balance in order to reach the balance of the nafs. In the Hadith, Muslims are encouraged to balance the needs of the self and the needs of the others around such as family members. That the believer needs to revise his life frequently in order to make balance in everyday activities, family, work, and relationships is reflected in the following Hadith:
There is share for your eyes, share for your own self, share for your family. (Sahih Muslim p. 564).
Change: transferring the self
Muslim scholars emphasize the importance of this concept in the context of the relationship with Allah (Qutb 1979; Ibn Kathir 1966). I found from my reading of the Qur’an and the Hadith that efforts to change are an important notion that underpins the help-seeking process. Changes in the human situation and improvements in individuals’ lives are associated with changes within. The transformation within implies the alteration of cognitive thinking as well as of the emotions. This consequently will affect individuals positively. Accepting or dealing with life crises requires the person to think about what they have been doing and what they need to change spiritually, cognitively and behaviourally. The act of change requires the person to be dynamic and not static. It needs knowledge and commitment. Referring to the link between the progress in any situation and the striving to modify the inner self and achieve a change in that situation, the Qur’an states:
191 Verily never will Allah change the condition of a people until they change it themselves (with their own souls) (Qur’an 13:11).
Saber: patience, the ability to endure
The word saber (patience), as Ali explains in his translation of the Qur’an, holds ‘many shades of meanings’:
(1) It implies patience in the sense of being thorough not hasty; (2) patient perseverance, constancy, steadfastness, firmness of purpose; (3) systematic as opposed to spasmodic or chance action; (4) a cheerful attitude of resignation and understanding in sorrow, defeat, or suffering as opposed to murmuring or rebellion, but saved from mere passivity or listlessness, by the element of constancy or steadfastness, the ability to endure (p. 28).
While looking for help, the person is expected to be patient and tolerant. This is emphasized in the Qur’an:
11. O ye who believe! Seek help in steadfastness and prayers. Lo Allah is with the steadfast (2:15).
Saber, as well as being patient and tolerant, is important for succeeding in the journey of help-seeking:
7. O ye who believe! Endure, out-do all others in endurance, be ready, and observe your duty to Allah, in order that ye may succeed (Qur’an 3:200).
Endurance is supposed to be encouraged within the Muslim community. Individuals need to support each other to endure the hardships and difficulties of life. It is considered as a part of the person’s social responsibilities.
By the declining day, Lo Man is in a state of loss, those who believe and do good works, and exhort one another to truth and exhort one another to endurance (103:1,3).
192 The more individuals are patient and show endurance, the more they will be given strength to deal with whatever problems they have.
Allah’s messenger said ‘He who shows endurance, Allah would grant him power to endure, and none is blessed with an endowment better and greater than endurance (Sahih Muslim p. 503).
Asking for Allah’s help needs to be accompanied by patience. The Qur’an acknowledges the difficulties human beings go through and the difficulties in being tolerant. On the other hand, These are also considered to be what makes a person a strong believer. The purpose of hardship in life is to strengthen the relationship with God:
Nay, seek (God’s) help with patient perseverance And Prayer: It is indeed hard except To those who bring a lowly spirit (Qur’an 11:45).
Or again:
Ye who believe! seek help With patient Perseverance And Prayer: for God is with those Who patiently persevere (Qur’an 2:153).
Hope
The concept of hope is mentioned frequently in the Qur’an and the Hadith. It is one of concepts which was strongly linked by particpants to the help-seeking process. In this context the believer will always have hope in the possibility of overcoming problems and difficulties.
So, verily, with every difficulty, there is relief: Verily, with every difficulty there is relief (Qur’an 94:4,5).
As hope is part of being a believer, harming of the self is forbidden in Islamic tradition. There is always hope. The killing of the self is considered a sin in Islamic
193 teaching. If the Muslim does harm to the self he will not be granted heaven after death.
The Qur’an says:
Nor kill (or destroy) yourselves: for verily God hath been to you Most Merciful! (Qur’an 4:29,30).
Neither is the wish for death allowed. It is considered a sin, as the Prophet said:
None of you should wish for death because of a calamity befalling him (Sahih Bukhari v8 p.202).
On the other hand, if the pain is too hard to endure the person can say:
O Allah! keep me alive as long as life is better for me, and let me die if death is better for me (Sahih Bukhari v8 p.202).
Al hamed: contentment with Allah
To build a good relationship with Allah, and in order to get the help of Allah, the Qur’an and the Hadith emphasize that a person needs to be grateful and thank Allah for everything. In the Qur’an the concept of showing gratitude to Allah for everything is mentioned in many places:
Nay, but worship Allah, and be of those who give thanks (Qur’an 39:66).
Then do ye remember Me; I will remember you. Be grateful to Me and reject not Faith (Qur’an 2:152).
Appreciating Allah is not only to take place during the easy times but also during the difficult and distressful times, during the misfortunes in life or the hardships encountered. This is due to the notion that the difficulties in life are trials,
194 blessings, or to prevent worse things from happening. This notion is expressed in one of the Hadith.
Strange are the ways of a believer for there is good in every affair of his and this is not the case with anyone else except in the case of a believer for if he has an occasion to feel delight , he thanks [God], thus there is a good for him in it, and if he gets into trouble and shows resignation (and endures it patiently), there is a good for him in it (Sahih Muslim p. 541).
Expressions of faith by participants
The relevance of religious beliefs to help-seeking and coping with mental health problems was strongly present in the interviews with most male and female participants. Issues of spirituality were mentioned directly or indirectly by them. Different aspects of spirituality were adopted as a precondition to looking for help. I found these elements to be the basic values for many participants which instigated their journey of finding help.
Faith and Taqwa
Strengthening of the relationship with Allah was seen by many of the participants as the only way to cope with their difficulties in life. Allah was considered the source of healing, and the only way to overcome mental health problems, which indicate a strong link to the Islamic teaching and philosophy, as indicated in the Qur’an and the Hadith.
Nida, one of the female participants, talked about her belief in Allah’s will in relation to the healing of her problem. In spite of her frustration with the psychological problem, there was a belief that the only source of assistance was God. Al-Krenawi (1999) asserts the same concept, which was clearly identified by participants in this study.
195 I do not imagine there is anything, can help me in my problem. Only God can help.
Some considered that having faith and following religious instructions was the way to survive and to overcome the problem of mental health. The safeguarding of Allah’s commands and the practice of religion prompted their efforts in getting help.
Baheera, one of the female participants, told me:
Faith in Allah is the only hope.
Mahmoud, one of the male participants, also said that he depends on God to help cope with his psychological problem:
I need to depend on God. Everything is in his hand.
Some talked about their relationship with God as the basic element of healing. If Allah is the centre of the life of a human being then individuals would have better ability to find ways to cope with mental health problems. Faith is considered to help in dealing with problems in which human beings cannot achieve change. Such a notion is identified in Islamic tradition, for example in Qur’an 26:80. Jameel, one of the male participants told me while he was discussing his journey of seeking help how his faith helped him to cope with mental health problems.
I personally believe in the importance of considering God the centre of human life. It helps in solving life problems.
Another male participant said:
I think that having faith and taqwa in Allah is a very important issue in life. It might help in solving difficult problems.
196 Participants frequently mentioned their dependence on Allah in relation to help- seeking. Such dependence was associated in their discussions of the strategies they had initiated to find support for their problems. It was mainly linked with the looking for practical help, such as visiting traditional healers, but also played a role in their seeking professional help.
This subject and the meaning of dependence on Allah was the content of the discussion of Burhan, one of the male participants who was keen on explaining that his action was tawakul or ‘depending on Allah’ and not tawakul ‘not trying to do anything to solve the problem while asking Allah for help’. He said
I would like to tell you that I have tawakul and not tawaakul. tawakul: is to do your best to achieve a good result at the time that you believe that the end result is what Allah will do. tawaakul: Is to do nothing, waiting and hoping that results on a specific matter will be based on what is Allah will do.
Burhan further explained how he perceived his help seeking journey:
My seeking for the treatment here is a sai [working towards a goal]. For me the treatment is first and then I ask the help of God. I took the medication and then asked God to heal me. I didn’t ask God then looked for the treatment. There is a difference between to depend on God and to depend on God without initiating any effort.
Baheera, one of the female participants, also indicated this concept in her discussions about help-seeking. She talked about her frustration with her psychological problems, and how she considers her dependence on Allah a motivator to cope and to find ways of dealing with her mental health problems.
Tawakkult [relying on Allah] and I came to the clinic to see if there is any help in my case. I always say (God I count on you). I don’t have anything else I can do. Everything is in Allah’s hands.
197 Al hamed
Thanking Allah, even after discussing a painful experience, was one of the most common expressions of most male and female participants. Many spoke of the notion of thanking Allah for all things. Many mentioned the words Al hamed lil Allah on many occasions in their conversations. Al hamed was a statement that they were accepting of the trials of Allah and submitting to Allah. It was part of the general approach to help-seeking.
The expression Al hamed was frequently mentioned by both male and female participants, especially those who identified themselves as religious. This was in order to remind themselves of the need to be accepting, or of when there are feelings of guilt for not being patient enough. Nida, one of the female participants, said:
We should thank Allah for anything, everything.
Alwan, a young male participant, told me:
Al-Hamed lil Allah [Thank Allah]. This is what Allah decreed for us.
One of the concepts which emerged from the discussions with male and female participants was the acceptance of their mental health problems, especially when they compared themselves to others in worse situations.
Al hamed lil Allah. It is a trial from Allah. I am always thanking Allah. It could have been worse. I see some people with more difficult and complicated cases when I come to the clinic [he means people with psychotic illness accessing the clinic].
Al hamed lil Allah. At least there is a possible treatment.
198 Istighfar: asking Allah for forgiveness
Prayers for forgiveness were the most important prayers which were mentioned to help overcome the problem of mental illness. These prayers were to alleviate any sins or wrongdoing by individuals. Sins supposedly prevents Allah’s mercy. Istighfar, then, are prayers to strengthen the relationship between the human being and Allah. There are some Dua’ [prayers] in order to overcome particular problems. The Istighfar are also done on a regular basis by some to bring the blessing of Allah. Mahmoud, one of the male participants, said:
I continually recall specific Ayat [Qur’anic verses]. It is sort of praying for forgiveness, and to praise God. For that the person would make God the centre of his life.
Maryam, another female participant, considered her mental health problems as a blessing to reduce sins, punishment, or trials. She used the Istighfar, asking for Allah’s forgiveness, as a way to strengthen their relationship with Allah and to cope with her mental health problem:
My psychological problem is cleansing from sins. We ask Allah for forgiveness. Allah answers our prayers with Istighfar.
Expressions of asking for forgiveness by participants were commonly made when there were complaints or expressions of dissatisfaction, or when participants discussed a negative behaviour of others or described of their own symptoms. The words of Istighfar were said to assure themselves that they were accepting of mental health problems as a trial.
Nour, one of the female participants said:
The psychological problems are really bad. Sometimes I can’t stand myself. Astaghfir Allah [God forgive me].
199 Change
While change is an important aspect in the help-seeking process in the Qur’an and the Hadith, it was not mentioned directly by participants as the way to find healing or to improve their lives. Some talked about change happening to them in terms of being spiritually stronger in coping with their mental health problem. This was however not directly explained in relation to coping or help-seeking.
Saber
The concept of Saber was one of the most commonly discussed themes by male and female participants. The enduring of mental health problems was mentioned in relation to the duty of a believer to be patient in dealing with such problem as part of being a believer.
Muhseen, one of the male participants, who had been suffering from depression and stated that he was findings difficulties in undertaking some of his duties as a Muslim, still considered that being tolerant was important in coping with the problem. He said:
I tell myself I need to be tolerant. I keep trying to calm myself.
Amal, one of the young female participants said:
We will be rewarded for our Saber. It is a trial.
Patience was also related to accepting possible interventions to cope with the problem. Some participants talked about the need to be tolerant when they talked about the journey of help-seeking and the difficulties associated with it. This was related to the belief that looking for treatment is part of the Muslim’s duty (Qur’an 2:195). One of the female participants recognised that the need for saber is also
200 associated with the taking of medication and with waiting for the positive results of medication or psychological help.
Maryam, one of the female participants said:
I have been taking medication for couple of weeks but I need to be patient. I haven’t seen good results yet. I know I need to be patient. I will keep trying.
The is a need for a person to be tolerant in dealing with difficulties associated with the effect of mental health problems was clearly suggested. Suad told me:
I am not able to clean the house any more as I used to be. I am not able to do that any more. I used to have more energy. I lost that now. What can we do? We have to be patient.
Hope
There were occasional references by participants to trusting Allah and having hope. These were linked to belief in the words of the Qur’an:
So, verily, with every difficulty, there is relief. Verily, with every difficulty there is relief (Qur’an 94:5-6).
Jameel, One of the male participants, for example, stated:
In sha Allah, God willing I will recover.
Maryam, one of the female participants, said:
I have hope. I can be healed with God’s will.
201 The feelings of hope held a different meaning for some. For them, hope meant the ability to cope with the psychological problem, rather than a complete healing. Sami said:
I am happy with my situation now. I have a hope to be able to always cope with it.
Such hope was associated with feelings of acceptance of the current situation and trust in God. Firas, one of the male participants, reflected:
Honestly I do not think I will be relieved from the problem. I do not think it will totally go. But sometimes I feel satisfied with what I have achieved so far. I wish, I do not know how, I hope that in a moment, maybe all of a sudden, a miracle from Allah will happen, and things will change in my life. I have hope.
There were, on the other hand, some who said that they did not have any hope for a change in their situation. They spoke about losing hope, but not without expressions of guilt as this was considered not being patient and accepting, as they are supposed to be in Islamic teaching.
Alwan, one of the male participants, said:
I have lost hope. I do not feel I am getting better. If suicide wasn’t a sin, I would have committed suicide.
Nour, one of the female participants, said:
I don’t feel that I have a normal life. I don’t have hope in recovery. I hate my home, I can’t cook and I am not able to sit with people; God forgive me. They say you have to have faith in God. I feel I will never recover.
Nour further reflected on her mixed feelings. This was in spite of identifying herself as religious. She talked about how she felt she had few opportunities
202 because of her psychological problems as well as her social problem of being divorced. This combination of problems made things hard for her:
I most of the time do not like life. I wish I was dead. I have reached a stage where I feel I have no hope. I am not an 18-year-old-girl any more, and I am divorced. I feel my life is destroyed.
Ali, one of the male participants, talked about losing hope to the extent that he wished he was not alive. He reported:
I am a Muslim. I believe that suicide is a sin. If it wasn’t a sin I would probably have committed suicide.
Nour also talked about a similar concept. She told me how she had conflicting thoughts about suicide:
I discuss with my doctor my suicidal thoughts. I fight them. I would say to myself ‘I don’t want to die faithless.’ Other times I say it doesn’t matter any more.
These values and principles underly the help-seeking journey. They are the basics in building and strengthening the relationship with the Allah. The relationship with Allah in this sense is individual, confidential. Most participants discussed these values as part of their cognitive thinking which would be reflected in their spiritual relationship with Allah and consequently would empower them while seeking help. While these religious values were more discussed among participants who identified themselves as highly religious, other participants also said that these values were part of their cognitive thinking and part of their spiritual experience.
Summary
A number of basic principles which helped contextualize the help-seeking behaviour of Muslim people have been identified. Taqwa (piety) or safeguarding
203 Allah’s commands, asking forgiveness for wrongdoing, keeping balance in life between physical, spiritual or social needs, being tolerant, accepting, and not loosing hope in the possibility of improving or being healed, are all important aspects which underline the help-seeking journey. Central to all of these is that Allah is seen as a source of healing, and thus most participants talked about the importance of strengthening the relationship with Allah as a method of helping them to cope with their mental health problems. In the next section I will address the four major practical approaches to help-seeking which emerged from the discussions with participants. These are practices associated with religious rituals, the accessing of traditional healing, the accessing of professional help and the utilization of social support.
204
SECTION TWO
THE JOURNEY TOWARD HEALING
205
Part one: Practices for healing in Islam
To strengthen the relationship with Allah there are several practices and prayers which a Muslim has to regularly practice in order to fulfil his or her faith. The more the Muslim is, supposedly, committed to their faith and the more he or she is connected spiritually with Allah, the better this person will cope with mental health and other related problems.
Some of these practices are praying, fasting, charity, and reading the Qur’an. Some Muslim scholars consider that practices such as fasting, asking Allah for forgiveness, and constantly remembering Allah all have a healing effect on mental health (Husain 1998; Ahmed 1998; Ansari 2002).
It is clearly stated in Islamic philosophy that the fact that a person is affected with mental health problems will not minimize his or her chances for getting Hassanat or a reward for their work. This is identified by the Prophet in the Hadith when he says:
When a servant of Allah falls ill or goes on a journey, he is credited with an equal amount of recompense as he used to do in his state of health or when he was at home (Sahih Bukhari cited in Nawawi).
Salat (Praying)
In Islamic tradition Salat is considered one of the main and most important aspects in healing from any distress. Ahmed (1998), Husain (1998) and Al-Krenawi (2000) argue that prayers provide healing for some psychological problems and anxieties. Ahmed (1998 p. 45) even calls these prayers ‘confidential counselling’. According to Pennebaker, freely expressing our emotions through confiding in others can be a powerful catharsis and an aid in recovering from illness. This includes praying as a powerful means of confiding (Levin 2001 p. 87).
206 Praying is mentioned and encouraged in the Qur’an and the prophetic tradition on many occasions.
Ye who believe! Seek help with patient Perseverance and prayers: for God with those who patiently persevere (Qur’an 1: 153).
Dua’ (prayers): protection from distress
Prayers are the most common and significant spiritual practices in the world, a fact that mentioned by many scholars (Taylor, Chatters, Levin 2004; Javaheri 2006; Dossey 1996). In the Islamic tradition there are various prayers for dealing with sadness and anxiety (Ahmed 1998). Al-Issa (2000e) asserts that prayers in Islam are considered to be a method that brings healing to the sick.
There are some prayers or dua’ which were mentioned and recommended by the Prophet. These prayers are said to help in overcoming feelings and behaviours which are manifestations of mental health problems such as depression or anxiety. One of the prayers of the Prophet reads:
O Allah I seek refuge with You from worry and grief, from weakness and laziness (Sahih Bukhari v 8 p. 210).
As the concept of building one’s relationship with Allah is highly emphasized in Islamic tradition, making dua’ or asking Allah for help is an important way to foster this relationship with Allah. The Qur’an says:
Call on Me. I will answer your prayer (Qur’an 40:60).
Hassana (reward for a good deed)
According to Islamic teaching, individuals need to constantly work to improve themselves. Good behaviours counteract bad ones. If an individual commits a sin
207 and consequently is burdened with guilt, they are encouraged by religious tradition to perform a Hassana in order to deal with these feelings.
Verily the good deeds remove the evil deed (small sins) The is a reminder (an advice) dor the mindful (those) who accept advice (Qur’an 11:114)
The Qur’an and healing power
As Horrie and Chippindale (2003) assert, the Qur’an for Muslims is considered the ultimate book of the Islamic religion. The Qur’an has organized values for all aspects of life of human life, including health and healing values. Ahmed (1998) and Ansari (2002) argue that the Qur’an does not provide medical solutions or interventions for treatment, but provides Muslims with guidance on what to do and what not to do in order to be close to Allah, and consequently individuals will be guarded from mental health problems, or be able to deal with these problems more constructively. There is a belief in Islam and among Muslims that the Qur’an has healing power. The power of healing of the Qur’an is stated as follows:
And We send down of the Qur’an, that which is a healing and a mercy to the believer (Qur’an 17:82).
The Qur’an is also considered to contain sets of laws and guidance which will consequently encourage wellbeing and will help in healing.
O mankind, there has come unto you a direction from your Lord and a healing for the heart and for those who believe in guidance and mercy (Qur’an 10:57).
The practice of reading the Qur’an and rookia for healing is becoming increasingly popular within Islamic cultures, as Ameen (2005), Al-Krenawi and Graham (1999c) and El-Islam (1995) have argued. They further assert that in the Islamic world there is an increased emphasis on treatment by the Qur’an for many sort of illness, including mental health problems. There are a growing number of clinics for healing purposes. Some of the prayers or rookia of the Prophet were for
208 protection from the evil eye and the possible effects of witchcraft. There are two Qur’anic scripts which are called Mu’awwadhatain. The Prophet Muhammad encouraged his followers to read them for protection, including from psychological problems.
There have been sent down to me the verses the like of which had never been seen before. They are the Mu’awwadhatain (Sahih Muslim p 388).
The Prophet ordered his followers to read rookia if they thought there was some effect from an evil eye (Sahih Bukhari V7 p.327).
The Prophet said ‘Say, I seek refuge with the Lord of the dawn’ and ‘Say, I seek refuge with the Lord of men’ (Muslim 1978 p. 388).
The Mu’awwadhatain are important ayat or verses in the Qur’an which are mentioned for protection from any evil which might cause distress or any other sort of harm.
Zikr or praise of Allah
Praise and Zikr (remembering Allah) are important recommended practices in the Islamic tradition. By practising them individuals strengthen their relationship with God. Muslims are encouraged to keep remembering Allah. Praise is a way of strengthening the relationship with Allah. The Qur’an says:
Praise be to God, The Cherisher and the sustainer of the worlds (Qur’an 1:2).
It is believed that the frequent mentioning of Allah’s name brings contentment and delight to the heart of the human being. The concept is frequently mentioned in the Qur’an:
209 Those who believe, and whose hearts find satisfaction in the remembrance of God: for without doubt in the remembrance of God Do hearts find satisfaction. (Qur’an 13:28).
Social role as part of religious practice
In Islamic traditions, the obligation of Muslims is to support each other in order to have a righteous society. Turning to others and seeking their support in society, whether they are family members or friends, is an important source of coping. Concepts such as cooperation, maintaining blood relations and helping the needy are stressed within Islamic teaching. These concepts were spoken of by participants as they talked about their perceptions in terms of seeking help and the support of others around them. Co-operation within the community is emphasized in the Qur’an:
And turn unto Allah together, O believers, in order that ye may succeed (Qur’an 24:31).
Removing difficulties and being co-operative with others is seen to reflect on the self. The good act will be rewarded. The co-operation and the help offered to a person while vulnerable could be also offered by a person who is suffering from these with mental health problems to others in hard circumstances.
One who removes the difficulty of a Muslim, Allah the Almighty will remove one of his troubles on the Day of judgment. Similarly one who covers (clothes) the faults of another Muslim, Allah the Almighty will cover the former’s faults on the Day of judgment (Bukhari and Muslim, cited in Nawawi, p. 56).
Everyone has a social responsibility which needs to be fulfilled. The father, mother, sibling, husband and wife all need to take responsibility towards each other, in order to have a strong family, society, and world. Taking care of each other indicates that people who are going through hard circumstances, such as mental health problems, will be cared for.
210 The Prophet said:
Beware, every one of you is a guardian and every one of you shall be questioned with regard to his trust (Sahih Muslim p. 17).
Practice of healing by participants
Participants indicated that they had undertaken different healing practices such as praying and fasting. The most common practice which was mentioned by participants was the Qur’anic healing, dua’ (praising Allah).
Dua’ Prayers
From the discussions with participants I found that praying was frequently mentioned in their practising of Islam. Some would make dua’, asking Allah for help as part of their conversations, when they talked about their mental health problems. Dua’ was also mentioned frequently as a way of participants coping with their problem. Some would quote script from the Qur’an on the importance of dua’ and how Allah responds to believers who genuinely pray asking for help.
Baheera, one of the female participants who identified herself as religious, reported how she used dua’ as one of her strategies:
I constantly make dua’ for Allah to help me. Prayers are a source for help.
Some shared some of the prayers which were recommended by the Prophet in the Hadith to heal sadness and anxiety some of these were dua’.
The Qur’an and Rookia
The Qur’an was considered to be a source of healing for many participants, and mentioned frequently by male and female participants. The emphasis on the Qur’an
211 as a healing method by individuals with mental health problems is also indicated by Al-Krenawi and Graham (1999). Many participants considered that the reading of some of the Ayat has a healing power, when read on the person when suffering from distress. Ali, one of the young male participants, reflected on the healing power of Qur’an. He said:
There are some scripts in the Qur’an which heal sadness and distress. It is the religious rookia.
Mahmoud, one of the male participants, described the rookia he used:
To help me to cope with the problem I read rookia. It is about specific ayat, sort of praying for forgiveness and to praise God.
Hannan, one of the female participants, talked about her reading of the Qur’an to help her cope with her problem. She recognized that this healing is within Allah’s will.
When I am stressed, I will cry and read the Qur’an. The reading of the Qur’an helps in dealing with problems but it is still within God’s will. The Qur’an heals so many problems. But everything is Allah’s will.
Some male and female participants talked about the positive results associated with the reading of the Qur’an. The Qur’an helped them minimize the effect of mental health disorders. The effect of the Qur’an is seen as both a therapeutic and a preventive method. The treatment is applied in order to assist in coping with mental health problems. Fouad, one of the male participants, reflected on the positive results which resulted from Qur’anic healing:
Practically I feel more energetic. I feel less stressed. It is for sure that the Qur’an heals and has a psychological comforting effect. I mean I do now read the Adkar regularly, If I don’t read the Qur’an in the morning and recall Qur’anic script (then he mentioned some prayers) I feel I miss something. I mean it is something basic in my life.
212 The Qur’an was considered by some to offer protection. It protects human beings from all evil, whether hassad (the envy eye) or sorcery. As a preventive from evil, reading the Qur’an would keep people from further being affected by problems which affect their psychological wellbeing.
Hannan, one of the female participants, said:
The Qur’an is the best protection. There are some scripts in the Qur’an which have a healing power.
Burhan, one of the male participants discussed how his mental health problem might be due to the effect of an evil eye, and that he was trusting the healing power of the Qur’an. He reported:
We have some ayat in the Qur’an that we could recall to protect us. There are some ayat the person could read on the self and on the children. I wish I brought one of my children to show you how the eye affects them. Qur’an contains healing for the hearts. Isn’t healing what the psychiatrists are trying to reach. Qur’an is from God and not a human made. If you ask me if Qur’an could be a treatment, I would then say yes there is Qur’anic healing. We can’t contradict the Prophet’s traditions. There are some certain aya the Prophet told us about.
The Qur’an and the healing power of faith were considered more effective in dealing with mental health problems than western medicine. Burhan further reflected:
The Qur’an is the biggest source for the psychological treatment. It is the best. I think even more efficient than the western technology and the research and studies.
Maryam, one of the female participants, told a story of how she felt she was feeling unwell due to possible effects of the evil eye. She reported:
213 I also was envied a week ago. I treated that by reading the Qur’an for a whole week. Now thank God, I am better. I always read, hold the Qur’an and have the Qur’an tape always at home 24 hours a day.
Hannan, another female participant compared the effect of the Qur’an and other coping mechanisms saying:
I use the Qur’anic healing, and I am convinced of its affect. I am happy with it. Some might say music relieves you. Some might say they find music calming. I am not comfortable with that. For me I don’t feel relieved when I listen to music. Listening to Qur’an is better than music. It is more comfortable to be honest. The Qur’an is a miracle and a cure.
Hannan, on the other hand, did not find relief in hearing the Qur’an at the start of her mental health problem. This created feelings of guilt and led to her looking for the support of religious individuals such as a female Sheikh who helped to overcome the problem by providing special prayers. Her negative feelings when hearing the Qur’an were attributed to the possible effects of bad Jinn (devils). Hannan said:
At the start of my psychological problem, I didn’t used to like to hear the Qur’an, when I used to hear the Qur’an I used to feel annoyed. But thank God I always prayed and I always make dua’ for God to help me to overcome these feelings. Once when I attended the religious teaching the teacher gave me prayer to recall for 40 days first to pray then to make the dua’. I recovered, thank God.
Belief in the healing power of the Qur’an was proven for some after their condition improved.
The Qur’an helped especially at the start of the mental health problems. Fouad, told me:
I noticed especially in the beginning when the situation was very intense. The situation was much harder than I could bear. I wasn’t able to sleep unless I listen to Qur’an. The readings of the Qur’an made me feel relieved and the Qur’an sort of clamed me down.
214 Ali, one of the male participants, reported how Qur’anic healing helped him to get better:
When I tried the Qur’anic healing, and as soon as the Qur’anwas read to me, I felt there was an improvement. I felt the agitation started to diminish with the Qur’anic readings.
The effect of treatment depends largely on the degree of belief individuals hold: belief in Allah’s will and in the power of Qur’anic healing.
Mahmoud, one of the male participants, noted that healing by the Qur’an is associated with the degree of belief of the person. There is a greater tendency for improvement among those who believe in the healing effect of the Qur’an.
If the person was a strong believer they would experience the positive effect of healing. On the other hand if individuals were not believers there would be no positive effect. On the contrary there might be a negative effect.
The improvement brought about by reading rookie was also discussed. The reading of rookia or the Qur’an could be done by the person himself or herself or by a trusted other, like a wife or a friend. Some considered the reading of the Qur’an by a Qur’anic healer as not necessary as this can be done by anyone who believes in the healing power of the Qur’an. Mahmoud noted:
There is no need for a Sheikh to read rookia on me. I mean my wife can read rookia on me or may be I myself would read some of the Qur’anic scripts. Unfortunately I am not good at regularly reading on myself but I do sometimes. I do from time to time.
Hannan also discussed the same notion:
The Qur’an gives me some sort of relief. Any female relative or friend who I trust might read a rookia on me so I would feel relieved.
215 Qur’anic healing is not only to be implemented during times of distress. It is supposed to be a regular practice. It is considered a preventive strategy to keep the mental health problems from worsening. Burhan talked about how Qur’anic healing should be done.
We are not supposed to read rookia in the case of the illness or tiredness only. Whether you are tired or not tired. There is no harm in applying religious rookia. I mean every morning when a person is going out of home. If a person reads [mentioned some Qur’anic scripts …]
The reading of the Qur’an does not mean excluding medical treatment. It does not preclude the professional option. This has been asserted by scholars such as Al- Khayat (1997). Some participants talked about the combining of Qur’anic healing and professional treatment. Both methods helped in their cases, and did not conflict with each other. Lefley (1998) considers that using more than one method in help- seeking is common among non-western societies.
Hannan, one of the female participants, said:
The Qur’an gives me some sort of relief. But psychologically and my treatment for the problem of anxiety has to be with psychiatrists. I highly respect the Qur’an, but I am sick and I need to be treated by a psychiatrist.
Ali, one of the male participants who used Qur’anic healing, stated:
I intend to keep getting medication and to continue the preventive treatment with the Qur’an. There is no problem in combining both.
Baheera, one of the female participants said:
There is a healing method when you read and repeat God’s names, and to praise God, and to read the Qur’an. This is besides the medical treatment. Nothing else.
216 Examples of some other religious practices
Helping the needy is one of the religious practices which was practised by some in order to gain forgiveness and hassanat. Nida said
I constantly give sadaka.
Going to Omra (going to Mecca) was seen as helpful by some. The practice was seen as a therapeutic strategy in dealing with mental health problems. Hannan said:
I went to perform Omra. It helped me a lot.
Social Role
Many of the participants talked about their social role. They talked about the effect of mental health problems on their interaction with others, such as family members, and about the difficulties in undertaking their responsibilities within the household and at work. Many expressed feelings of guilt associated with these difficulties. Talking about these roles, however, was not linked directly to religious practice. Sami, one of the male participants who identified himself as religious, reflected on the change in his roles after he was affected by a psychological problem. The mental health problem prevented him from performing his duty towards his family. He reported:
The problem affected my relationships with people, especially with my wife. When my psychological situation was intense I tended to live in isolation. I didn’t care about her. I didn’t care about the children. I stopped helping them with their homework. I stopped taking them out. I used to visit my family then I stopped once I became ill. I became isolated. I used to stay in the mosque, or at home, reading Qur’an. Even at work my colleagues noticed and they commented ‘What is wrong with you, you became very serious and you stopped joking around like you used to before’. I mean it changed my life. I used to have a certain personality and then all of a sudden I changed. Even people noticed that.
217 Suad, one of the female participants, talked about her difficulties in relation to her parenting role:
I used to like to draw; I used to love it so much. My daughter is the same. She loves it too. Since I got the disorder, I stopped drawing. I don’t like helping my children with their studies any more. My eldest son got low marks. I stopped caring about teaching him. I would tell him just go away. I just want him to go. He would throw his bag and leave home. My daughter is not studying too. She used to have very high marks at school. She is in year 5 now and she gets lower marks.
Mahmoud, one of the male participants, said:
I was under the threat of being sacked from my job because I failed to show up at work so many times. I don’t have any income apart from this one. I was worried about how I was going to pay the rent. I have four children. The more I think this way the more I would have problems.
The effect of psychological problems on the practice of religion
While most participants talked about using religious practices as part of their help- seeking process, some discussed not being able to practice their religion because of their mental health problems. The effect of the psychological problem minimized their abilities to use what was considered an essential coping strategy for them. This consequently caused them feelings of guilt.
Nida, one of the female participants who identified herself as religious, said:
When I am under stress I do not read the Qur’an. I even do not pray the sunna. I used to make up for the days I didn’t pray when I was younger, but now I can’t. When I am stressed I only pray the fard [the required five prayers] But when I feel better I would read the Qur’an and I would pray sunna [extra prayers apart from fard]. But when I am nervous I wouldn’t, because I can’t concentrate. I tried once and I wasn’t able to. I didn’t know what I was reading.
218 Shakeera, another female participant, said:
My prayers are not the same. I mean I only pray the five prayers, and I force myself to pray. It is hard because of the stress. God forgive me.
One of the males also said:
I haven’t prayed for two days now. I am not able to.
While most of the literature states that people tend to use religion as a coping strategy to deal with their mental health problems (Taylor, Chatters & Levin 2004; Al-Issa 2000c; Pargament 1997) this study found that there were some who found it hard to practice some aspects of their religion. This was due, as they indicated, to their psychological problems.Part two: Looking for practical support
As was indicated at the start of this chapter, taking care of one’s health is one of the obligatory duties of a Muslim. In contrast not taking care of the self or causing the self any harm is forbidden in Islamic traditions, as noted at the start of this chapter. The discussion of the help-seeking provided by participants will focus around three main thems: traditional healing, medical healing and the seeking of social support.
Traditional Healing: the Sheikh
Al-Krenawi and Graham (2003) argue that traditional healing is considered one of the main sources of help within Islamic cultures. Ameen (2005) notes that folk healers vary in Muslim cultures. They have different names and different methods of helping individuals with distress. Kleinman (1980) and Helman (2000) consider that the significant role of the healer is to help the individual to get rid of the cause of the problem, and to help in fostering social cohesion in the family and the community. They further assert that the healing might provide an opportunity for
219 talk therapy, which resembles forms of psychoanalysis, psychotherapy and counselling in western cultures.
The concept of Sheikh (male) or Sheikha (female), as discussed by male and female participants, indicated different meanings. The common meaning of Sheikh in Islamic cultures is a person who acquires religious knowledge and who can provide assistance and support for people in their care with regards to religious and daily life issues. Most of the time the Sheikh is the one who has studied religion in schools or universities. Some religious individuals could be called Sheikhs by others to indicate respect for their being highly religious.
On the other hand some who might be called Sheikhs were called musha’awead (male) and musha'aweada (female) by participants to indicate that they were fraudulent. They were considered individuals who claimed that they had some sort of supernatural ability, practiced witchcraft and sorcery, or claimed that they have the ability to contact spirits and to affect others. This sort of practice, as well as fortune telling, is strictly forbidden in Islamic religion. Individuals who are religious usually do not get help from a musha’awead or a Sheikh who claims to have supernatural abilities, as many scholars have indicated (Qutb 1979).
Views about characteristics of a good Sheikh
Most participants talked about good Sheikhs. A good Sheikh is one who helps individuals to strengthen themselves spiritually. A good Sheikh assists individuals in coping with their mental health problems. There are different characteristics of a good Sheikh: they are well informed about religion, spirituality, and the Qur’an. They also supposedly practice religion.
Mahmoud, one of the male participants, said:
220 The Sheikhs should be good people. They should be on a good level of education and knowledge.
A good Sheikh often has had a previous experience with someone trusted close to the person going to visit them, and has been recommended. Fuad, one of the male participants, said:
There are Sheikhs who you know, or you trust them, or you trust people who might introduce them to you. You do not want to be taken to musha’awead, and that sort of nonsense.
A Sheikh should not take any money in return for his or her reading of the Qur’an. Charging money for reading the Qur’an means that the Sheikh is not doing the job for the sake of Allah but making reading the Qur’an a business.
Maryam, one of the female participants said:
The Sheikh who takes money is a liar and Moushauade. The one who doesn’t take money is the one who is honest. The Sheikh I went to is of that kind. He does the healing for the sake of God only.
A good Sheikh will use scripts from the Qur’an or from the prophetic traditions in the healing process. If a Sheikh uses some sort of language that cannot be understood (i.e unfamiliar words which some sorceress might use) this might indicate that he or she is not a good Sheikh. He or she could be a musha’awead or musha'aweada. Maryam commented:
But I mean if he was talking any nonsense, rubbish sort of talk, I wouldn’t have stayed in front of him. I stayed only, when I heard with my own ears what he was saying.
A good Sheikh has knowledge of the Ayat and rookie, which treat the possible effects of Jinn. Ali, one of the male participants, said:
221 The Sheikh I went to was a knowledgeable one. Allah blesses him. He used specific rookia to treat the effect of Jinn.
The Role of Sheikhs
Participants discussed different roles and influences for Sheikhs. The Sheikh’s role is to help individuals to make sense of their experience by re-framing it in a culturally symbolic concept. Helman (2000) and Kleinman (1980) note that reaching these points provides individuals new ways of to looking at their past and present experiences, and of acquiring confirmation from the healer of their prospective healing.
Some of the emerging themes which are related to the role of the traditional healers were:
Calming role
Participants talked about the different approaches the Sheikh can use in order to help a person minimise the amount of stress associated with their mental health problem. The Sheikh might use scripts from the Qur’an to help the person to be less agitated and more energetic. He or she also might help the person to make sense of the psychological problem based on Islamic teaching.
Firas, one of the male participants, simply described the role of the Sheikh:
I mean their role would be to calm you down.
Hannan, one of the female participants, said:
I went to the Sheikh to help me to minimize the agitation which was affecting me. I felt much better after he read on me.
222 Diagnostic role
Some looked for the help of the Sheikhs before accessing mental health services. The help required was to determine the cause of the mental health problem. The investigation and the discussion would then determine the help needed and whether it was spiritual or professional help, and the Sheikh would consequently refer them to professional support (Lefley, Sandoval & Charles 1998).
Alwan, one of the male participants, reflected on how he came to decide that his disorder was psychological rather than spiritual:
I discussed my problem with someone who has the knowledge of spiritual issues. I wanted to know whether my problem was because of Jinn or because of the spirits or something like that. He explained how the Jinn enter the body, and what causes that. But for me I compared what he was saying with my situation and I found that my problem is far from these sorts of things. My situation needs a specialist. Let us say, it needs more than a Sheikh.
Amal, one of the female participants, talked, with some hesitation about the accuracy of the diagnosis of the Sheikh:
I went to a female Sheikh, who told me that some envious eye was affecting me. I don’t know if she was telling me the truth or not.
Nour, one of the female participants, said:
When I went to the healer he told me that I was under the effect of sorcery.
The role of a Sheikh is to diagnose the nature of the problem. The diagnosis of the Sheikh might be similar to the diagnosis of a psychiatrist. This would confirm what the psychiatrist had already said.
I mean when the Sheikh read the Qur’an on me, he said that you have fear, exactly as [then pointing to the direction of the psychiatrist’s clinic] the doctor
223 said. The fear is in my stomach. I do really feel my stomach tense. When I feel the fear I always feel pain in my stomach.
Some reached the conclusion that Jinn were the cause of their psychological problems with the assistance of a sheik. The Sheikh would have explained the effect of Jinn, and might also have informed individuals accessing his help of some details about how the effect happened. The Sheikh might also provide a description of people who initiated the Sihr. Maryam, one of the female participants, said:
The Sheikh said it was sorcery and Jinn. I asked him who would do that to me, and he said that it was my mother-in-law and her sister. He gave me their names, and descriptions. He told me their names.
Healing role
Maryam described how a Sheikh helped her in dealing with her problem:
I was told by the Sheikh that I was envied, and he treated me with the Qur’an, and recalled Allah’s name.
The healing role might be not to totally get rid of the problem but to overcome some of the symptoms. This part of the healing process might help in some cases to improve the situation and consequently enable some individuals to deal with their problems more productively. Rania said:
I improved a lot. I was relieved, and some of the symptoms did disappear. At the same time I realised I am not able to go back to the previous state.
The role of the Sheikh might be carried out by a relative or close friend – anyone who can read the Qur’anic script and believes in the healing power of the Qur’an. Mahmoud, one of the male participants, said:
I never have been to a Sheikh before, but not because I didn’t want to go to a Sheikh to read on me or anything. It is just that my wife always read the Qur’an for me.
224 Jameel, one of the male participants, did not consider the need to go to a Sheikh to read the Qur’an. He said:
Any one of your friends could calm you down with the reading of the Qur’an. For some people it is the wife, the friend, the neighbour, all could calm you down. This role could be performed by anyone.
Baheera, another female participant, said:
I do not believe in going to the Sheikh to read the Qur’an on me. I can read the Qur’an myself.
Participants who accessed the help of Sheikhs reported various experiences. Fouad described his experience with Qur’anic healing by saying:
I believe that there was a demon because I felt it while getting out. I used to have thoughts but I didn’t know where I got them from. As if there was a source for my thoughts that confused and prevented the organization of my life. While sleeping I used to see nightmares, very bad ones. I used to see myself in my dreams being killed, hit, and getting raped. In the dream the true feelings are present. I used to wake up tired and in a bad mood. I used to hate to sleep. After being treated with the Qur’an, by a Sheikh, all these symptoms have disappeared.
Some rejected the idea of getting the help of any Sheikh. They considered them to be deceptive. Some rejected the idea of using the help of a musha'awead as this is forbidden in Islamic traditions.
Nour, one of the female participants, said:
I never asked for the help of Sheikhs, or to have ‘hoojoub’ charm and this sort of nonsense. Never.
In spite of the recognition of some of the participants of the role of the Sheikh, some acknowledged the difficulties in recognising a good Sheikh. The reason given
225 was that some might treat the healing as a business while not having the knowledge to practice healing.
Hannan, one of the female participants, said:
Some of the Qur’anic healers are religious and you trust them, but others are not strongly religious. You can’t be sure of them as healers.
Firas, one of the male participants, said:
I know that some of them are honest. Honest, but it is hard to know who the honest one is. If I know who is the right one I would go to him. Some might take the healing as a profession and as a matter of fact they are not really knowledgeable.
Individuals who used musha'awead said that they felt that they had no other choice. Getting the help of a musha'awead was something which was done out of desperation. It was a part of the journey of making sense of the pain they were going through. Sami, one of the male participants told me:
Because my situation is so mixed up and the situation in my home is very bad I would go to any place where I could find help whether it was Sheikhs or anything else.
He reflected further on how this was something against his beliefs as a religious person. He talked about the experience with regret and embarrassment:
If someone talked to me about the subject of going to a Sheikh before I got sick, I would laugh and think of them as crazy, but I didn’t have a choice except to go to them. I used to deal with them hoping that they might help me. I mean I didn’t have any other choice. My problem is not a physical illness. The problem started all of a sudden. I didn’t feel any better when I visited the Sheikh. I know, however, it is not acceptable religious-wise. It’s forbidden, but you know when you are desperate you don’t know what to do.
226 The musha'awead might delay the accessing of mental health services. They might influence individuals with mental health problems by attacking mental health professionals. Muhseen, one of the male participants, said:
The Sheikhs told me not to take any medication. They told me that doctors and psychiatrists are liars, and empirical. Honestly that is what they say, so I refused to take any medication. Sometimes Sheikhs destroy and mislead people.
The effect of some Sheikhs (musha'awead) was considered negative because it gave the wrong impression about mental health professions. This was because of the conception held by some of them that there is no such thing as a mental health problem.
The Sheikh said that there is no such thing as mental illness, and it is all sort of a lie.
Reasons for accessing Sheikhs
The reason for accessing traditional healers is to get support in relation to spiritual needs. The ambiguity of mental health problems encourages individuals to request the help of Sheikhs to help them to make sense of mental health problems, enabling them to ask questions about how invisible forces have an effect on human beings. Psychiatrists on the other hand generally tend not to respond or acknowledge the influence of the Jinn, sorcery, or Hassad (Lefley, Sandoval & Charles 1998).
Ali, one of the young male participants who was using some Qur’anic healing to help him to deal with his mental health problem, told me:
Psychiatrists sometimes deny the spiritual part. I mean this sort of influence is present even though we do not know how it affects us.
The lack of acknowledgement of spiritual issues by mental health professionals encouraged some individuals to access traditional healers. When dealing with the
227 mental health professions, many individuals, as well as their families, hide the fact that they have had access to folk healing. This was due to their understanding of the negative attitudes mental health professionals hold about traditional healing (Lefley, Sandoval & Charles 1998). Fouad reflected:
The psychiatrists do not to know this issue. That’s why people are using Qur’anic healing.
Accessing Sheikhs was not seen to be enough on its own. This was because of the lack of awareness of the scientific part of mental health problems by these traditional healers. Fouad said:
The spiritual healers, on the other hand, do not have enough knowledge about the medical part. That’s why we need to access the clinic.
For some of the participants there was not enough satisfaction with the treatment of mental health services. Accessing these services helped in dealing with their problem but did not totally overcome it. For them, a response to the spiritual side was important; it was part of a holistic approach to treatment. Ali, another male participant, explained:
One of my friends told me about the Qur’anic healers. He said that he knew someone who might help. He told me ‘You have tried psychiatrist treatment and other things, how about trying also the Qur’anic healing’.
The approaches used by Sheikhs
As was indicated by participants, Sheikhs use different methods. There are some who only read the Qur’an, which is acceptable in Islamic tradition. The other sorts of Sheikhs are these who use different methods and mainly follow processes which are not part of Islamic religion. In this study, all male and female participants considered the accessing of traditional healers who do not use Qur’anic healing as a forbidden practice. Most of the participants did not think that there was a need to
228 go to any Sheihks to read the Qur’an on them, as this is could be done by anyone else around them.
Participants reflected in their discussions:
Sheikhs have different methods.
Some used Qur’anic healing.
The Sheikh used to read the Qur’an on me.
Others Sheikhs used methods which are not acceptable in Islam, like dealing with Jinn. Participants talked about not accepting these methods, and shared some of the experiences they had encountered with musha'aweads. Sami, one of the male participants, told me about his experience:
He was saying that he was dealing with Jinn, I don’t know maybe he wanted to mislead me and to let me think that he is dealing with Jinn. He was talking to others, whom I didn’t see. He was talking to something. God only knows. I haven’t seen who he was speaking to. Maybe with Jinn or … I don’t know if it was Jinn, or not.
Shakeera, another female participant, said:
The Sheikh gave me things to drink, and he read on me. He gave things to take for three days. I went to more than one and each one used to give me something different and told me also a different thing.
Some used different approaches, as Muhseen said:
Some of the things they used to tell me were not to watch TV for 30 days. Someone told me not to go to weddings.
Some used to treat me with herbs. Some used to give me things to shower myself with in the early morning for three days. Some gave me papers, some
229 oil, and some water on it. Someone told me that I was subject of Sihr [sorcery] and the the Sihr is in a grave. Someone told me that the sorcery is attached to a tree and when the wind shakes the tree you are affected with the illness. He gave some medication, but I didn’t feel better after taking them. I mean something, I don’t know, sort of medication and he also gave me something to drink.
Family views about using traditional healing
Accessing the Qur’anic healers or Sheikhs was mostly initiated and encouraged by relatives and friends. This is well reported in the literature (Aneshensel 1999; Mulatu 1999; Budman, Lipson & Meleis 1992). In this study it was also apparent that there were some cases where this sort of access was discouraged by some relatives and friends. The rejection of these practices was for various reasons, such as the belief that access of a Mushawad is haram (sin) or because of the belief that people do not benefit from traditional healing.
The visiting of a Sheikh is initiated most of the time by a family member or friend when symptoms of mental disorders are noticed. These symptoms might be attributed to the effect of spirits, Jinn, sorcery, or the evil eye. In such cases Qur’anic healing is considered to be the best healing method. A male participant said:
When I started to tell people about it, someone advised me to go to a Sheikh and to a fortune-teller, and that sort of thing.
A specific Sheikh might be recommended due to a previous positive experience by a friend or relative. Ali said:
People would usually suggest seeing a Sheikh. A friend and a neighbour of mine told me about the Sheikh.
Alwan, one of the male participants, said:
230 Actually, so many people told me about him (the traditional healer), so I said to myself it is not such a bad idea to try him.
Some felt curious about the visit to a traditional healer. They might have visited the healer without acknowledging this to their family, who might not agree on the accessing of traditional healers. Some family members objected to the idea of getting help from a Sheikh. Muhseen, one of the male participants, said:
My sister and brother told me that Sheikhs are liars, and I shouldn’t trust them.
The access of a Sheikh who is musha'awead is not without stigma. Seeing a young lady visiting a musha’aweada or female Sheikha might trigger many questions about the reason of the visit. This is in addition to the notion that getting help from a musha’awead is forbidden in Islam. Amal, one of the young female participants, told me:
I went once to a Sheikh without my mother knowing, she wouldn’t have allowed me if I had told her. She is worried that people might see me.
While research shows that traditional healing has a significant role in traditional societies (Helman, 2000), this study found that the role of some healers is diminishing as there is more dependency on professional help. There is an increased interest in healers who use Qur’anic healing and less interest in healers who are considered false Sheikhs. Some of the participants talked about their experiences with religious healers. They talked about Sheikhs who read verses from the Qur’an which have healing power. All agreed that visiting musha'awead or musha'aweada who do not use the Qur’an in healing was against their religion. Asking for the help from someone who might access Jinn, or sorcery is considered a sin in Islam.
Some admitted that they had an experience with some Mushaquds in the early stages of their disorder. They talked about these experiences with regret. Others did
231 not believe in accessing any help from a Sheikh as the Qur’an can be accessed by anyone who can read. There were no differences related to gender, or level of education, in relation to the decision about accessing the help of Sheikhs. Individuals who thought their psychological problems were from an evil eye, sorcery, or Jinn were more likely to look for help by strengthening themselves spirituality, by reading Qur’an and sometimes by accessing Qur’anic healers.
The study shows that most people did not believe in the effect of Jinn in their particular case. For those who believed in such effect, they still did not approve of accessing traditional healers who were not using Qur’anic healing. This is possibly due to the increase of religious education, which considers the access of Mushauds to be a sin. Other aspects, such as the exposure to more information about psychological problems might have contributed to the belief that mental health problems are disorders which can be dealt with in clinical settings.
Part three: Professional Treatment
Seeking professional help was discussed by participants. They mainly discussed the role of the psychiatrist. Not many spoke of the role of other mental health professionals. Many would visit the clinic asking for the help of a psychiatrist rather than that of other mental health professionals. The reason was because they were not familiar with other roles of mental health professionals or because they accessed the clinic simply to get medication.
Some talked about the importance of seeking professional help as part of following religious traditions and taking responsibility for dealing with their mental health problems.
Burhan, one of the male participants, talked about his perception of help-seeking as part of his religious practice, and depending on Allah.
232 We are ordered to look carefully for help and then depend on God. You need to look for the recovery options, and then you need to ask God to heal you.
Jameel also discussed the same notion:
Our religion is a scientific one: get treatment, look for options, and then ask the help of God.
Baheera, one of the female participants, said:
As our Prophet told us, every illness has a treatment, and you need to look for the treatment.
Participants said that psychiatrists tended to deal with the problem of mental health by focusing on the physical side and not paying attention to social, religious or spiritual sides of the problem. Some participants considered there was an increasing need for the services of psychiatry and mental health services in general. This was because of the increase in social problems due to the increased interaction and influence of western traditions. Increases in social and mental health problems were also seen as a product of the encounter with technology
Perceptions of participants on the importance of psychiatric services were related to globalization. Ghalyun and Amin (1999) argue that globalization is one of the most widely discussed subjects in Jordan and in the Islamic world. The exposure to western traditions is seen by many as a threat to national and Islamic identity. Participants considered the influence of the West on society as leading to social problems, including mental health problems. Having problems that are created by interaction with the West requires methods which are similar to those which are used in the West. Jameel, one of the male participants reflected on the subject saying:
The services of mental health professionals are needed because of the changes in the world today, in technology and the media. The world is turning into a
233 global village. The habits, traditions, and the activities which are present in the West, and which created the need for the psychiatrist, are all transferred to us. I mean the consumption of products, the technology, and the communication. It is all here now. As a consequence everything in the West needs to be here too. We need help for the invasion of these new things, like the West has.
Views about psychiatry
Most of the experiences with psychiatrists were discussed negatively. The relationship with the psychiatrist was seen as being based on providing medication and not giving enough time to individuals with mental health problems (Marsella & White 1984). Fouad, one of the male participants who had been accessing a mental health clinic for more than a year, explained:
I would like to say that the psychiatrist is not co-operative. He only provides me with medication. I feel I go to the psychiatrist to give me medication. I do not feel that the psychiatrists makes an effort or try to understand me and my personality. Psychiatrists do not try to understand the reasons for the disorder, so I wouldn’t have the problem again.
Providing time was one of the most discussed points. This is probably because of the shortage of psychiatric services in Jordan to meet the needs of the society, as Al-Krenawi, Graham, and Kandah (2000) have indicated. Salma, one of the female participants, said:
Psychiatrists do not give you enough time to explain your problem and to vent your feelings.
Some participants said that there was a tendency to have lengthy sessions at the start of their treatment, and then the sessions would gradually be shortened to minutes. Sami, one of the male participants, said:
At the start, the psychiatrists used to provide me with more time. But the ones I am visiting now are not giving me enough time. I do not get enough time for discussions or conversations.
234 Some, however, did not expect more from psychiatrists. They were happy to have short sessions to provide medication and they did not see the need to have lengthy sessions or discussions. This was because they considered that they were coping well, and they had enough support and information. They saw the need for more time at the start of the problem, but did not see the need if they were in a stable state.
Sami reflected this by saying:
Now I don’t have a problem I come here just for the medication. When I first came I used to feel the need to see the psychiatrist for longer sessions. I used to feel the need to talk to vent my feelings.
For some the change of psychiatrists made it harder for them to talk about their problems. They preferred not to discuss their issue again with a different psychiatrist each time they visited the clinic. They avoided discussing their story with the psychiatrist so they did not have to discuss the problem and previous symptoms which brought them to have a mental health problem. Salma reported:
I am not talking any more about my problems. If I want to talk then I have to tell them my story again. So I just come here to take the medication and then leave.
At the start of the treatment the impression is that psychiatry’s role is to provide tranquilization: Muhseen talked about this by saying:
When the psychiatrist told me he would give me medication, I felt scared. I said to myself ‘Oh, he would give me heroin.’
Some doubted the effectiveness of the role of the psychiatrist in spite of accessing the clinic. Hussain, one of the male participants who had just been accessing the clinic, told me:
235 The problem in my head, the problem I have is there all my life. I don’t think psychiatry is able take it out of my head.
Some participants talked positively about psychiatrists. Amal, one of the female participants said:
I mean Dr M is kind and understanding. I guess it is easy to talk to him.
Burhan, one of the male participants also talked positively about this psychiatrist:
He is a very good one. He tolerates me. He is a very good psychiatrist, thank God.
At the start of their mental health problem some patients did not believe that medication could help them. Rania, one of the female participants, stated:
I didn’t used to believe in psychiatric treatment. I didn’t know that the psychological problem is like that. I used to question the need for the treatment. I thought that the treatment is not needed. But when I went to the psychiatrist I understood that the psychiatrist has a role, and it is important to have psychiatrists.
The Role of the Psychiatrist
Participants talked about different roles of psychiatrists, mostly as educators andhelpers. Psychiatrists were seen as having limitations in what they can and cannot do. Burhan, said:
I discovered from my experience with psychiatrists that they would give you medication, but they are not able to create a new human being out of you.
Psychiatrists were seen by some as trustworthy professionals, to be trusted in terms of their diagnoses and treatment interventions. They were seen as the experts, as is indicated by Al-Khayat (1997). Mahmoud, one of the male participants, said:
236 The psychiatrist knows more than I do.
Some participants perceived psychiatrists as being important, and said they needed to follow what the psychiatrist said even though it might not appear to be right. This was simply because psychiatrists had been educated and trained in universities. Hannan, one of the female participants, said:
Psychiatrists are sophisticated. When I watch a doctor on TV, or if I am talking to a psychiatrist, I still look at them with respect, even though they could be right or wrong. I would accept what they say. That’s how I feel.
Educating
The role of psychiatry is to educate individuals with mental health problems. The psychiatrist’s role in some cases is to explain to the individuals about their mental health problems. Sami, one of the male participants, talked about how the psychiatrist clarified to him that his problem was a psychological one and needed to be treated with medication and not by fraudulent Sheikhs.
The young doctor was very kind and understanding. He told me what mushaawdeen said about the problem is a superstition. He also said not to listen to those people. He explained to me that psychiatrists are specialized in the area. He also told me ‘Mental illness is like any other illness, so why is mental illness the only illness they do not call illness?’ He assured me it is a normal illness.
Muhseen, another male participant, told me about his expectation that the psychiatrist would to help him to develop more insight about the problem, in order to be able to make decisions in his life:
I think the role of the psychiatrist is to explain, and to help me to be aware of what could happen to me. Does the illness have a medication, which heals the problem forever? Am I going to totally cut the medication? I now know 70% about my problem but I still do not know if I want to get married. If the illness is going to increase or not. I mean I don’t know, that’s what I think. I don’t know whether my case is going to be better or is going to improve. I know it is in the hand of God. But I think the role of the psychiatrist is to explain to me and to help me to be aware of what would happen to me.
237 Reassurance
Maryam, one of the female participants, talked about the support and encouragement she was getting from her psychiatrist:
My psychiatrist told me, ‘You need to be patient, and to take the medication.’ He told me not to be affected by others who are putting me down. He said, ‘This thing has been going on for three years, and you can’t get rid of it in a day.’ You need time.
Problem solving
One of the young male student participants talked about how he needed further support and involvement from his psychiatrist to help him cope:
I wish the psychiatrist would assist me in building my life. I wish the psychiatrist would say to me ‘Let’s you and I build a structure to your life to help you. Let us plan how you are going to develop yourself in a year’s time.’
Religion and mental health professionals
Psychiatrists were generally perceived by participants as neglecting or not giving enough attention to the discussion of religion with individuals with mental health problems. They were seen as being more scientific, and generally tending not to discuss religious coping strategies with individuals who accessed their help. This supports the arguments of the growing literature in the field of the mental health professions, namely that the mental health professions have been ignoring the subject of religion in relation to mental health problems and coping (Koenig 1998; Larson, Milano & Lu 1998; Pargament 1997).
Psychiatrists were criticized by participants for not paying attention to the religious aspects of the individuals accessing their services. This was important for some who were particularly religious. Salma, one of the female participants, said:
238 I do not think psychiatrists care about the subject of religion as a starter. The three psychiatrists I had an encounter with, none of them asked me about my beliefs or thoughts.
Some avoided discussing the subject of religion or the accessing of traditional healers with their psychiatrist. Participants said that they avoided discussing what they thought was a possible cause of their mental health problem, such as Jinn or hassad. They also avoided discussing their intention to access or their access of folk healing. This, as they perceived it, was due to not being encouraged by the psychiatrist to do so.
When dealing with the mental health professions, many individuals, as well as their families, hide the fact that they had access to folk healing. This is due to their understanding of the negative attitudes mental health professionals hold about traditional healing (Lefley, Sandoval & Charles 1998). Ali, one of the male participant who linked the causes of his mental health problems to the possible effects of hassad or the evil eye and was accessing Qur’anic healing, said:
I can’t talk to them about the evil eyes. I never mentioned the subject to the psychiatrist. I don’t imagine they understand that.
Fouad, another male participant who identified himself as religious and who was also accessing Qur’anic healing for the possible effects of Jinn or sorcery, told me:
I have an understanding that the psychiatrist does not believe in these subjects. The psychiatrist might be polite and might agree with me. But he is not going to believe the things that relate to the subject of spirituality. He has a scientific mind, and he has studied medicine. The ways the others (spiritual healers) work is different than the psychiatrist.
Accessing more than one therapeutic help system is common within non-western societies (Edman & Koon 2000). Some participants talked about combining two ways of dealing with their psychological problems: the medical and the religious
239 (Lefley, Sandoval & Charles 1998). Fouad further commented on his using more than one approach to help-seeking:
Lack of interest on the part of psychiatrists created for me two ways of dealing with treatment. One style is to access the psychiatry and another one is to access Qur’anic healing. I would rather if I could share with my psychiatrist that I was relieved with Qur’anic healing. But if I did say anything about that, the response might be ‘No you are mentally ill and nothing of that sort is going to work with your case’, or ‘You are ill with such and such.’
Some of these impressions about the discrepancy between psychiatrists and traditional healers are fostered by the media. Sami, one of the male participants, learnt about the attitude of mental health professionals in relation to musha'awead traditional healing from TV:
I watched a discussion on TV about this sort of thing. There was a psychologist, a psychiatrist, and a Sheikh. The Sheikh was applying spiritual methods to treatment. The others were arguing that what was he doing is not right. They almost were fighting.
Before accessing the clinic, some asked about the psychiatrist’s beliefs in relation to Jinn, sorcery, and hassad and their effects. They sought information from individuals who had had a previous encounter with a psychiatrist. Ali, one of the male participants, told me:
I didn’t discuss my belief with him [the psychiatrist]. Before coming here, I knew that he doesn’t believe in the effect of Jinn.
Some would investigate the level of religiosity of the psychiatrist before accessing the mental health clinic. Individuals who had prior experience with the clinic many have recommended one psychiatrist or another based on their religiosity. Some were encouraged by individuals who had already accessed mental health clinics and had positive results. Mahmoud, one of the male participants said:
240 Before coming here I knew that my psychiatrist was a religious one. A friend of mine has been getting treatment by him and he told me about him.
Some discussed their need to find a psychiatrist who incorporated Qur’anic healing in the treatment, in addition to the western approach to treatment. Hannan, one of the female participants, said:
The good psychiatrist is the one who has the religious and the western-based medical knowledge.
She further reflected:
I would like to be treated by a psychiatrist who believes in the Qur’an and the Prophetic tradition. Like the psychiatrist I told you about. He believes in the Qur’an and Sunna. He didn’t contradict Islamic traditions. He has knowledge of the Qur’an and uses it as a reference. He also studied in the West. The experience of the religion and the scientific knowledge makes it easier to trust him.
In some cased there was a need to talk to a psychiatrist who believes in the possibility of the influence of Jinn. Fouad said:
Some psychiatrists might not believe in Jinn, sorcery, or envy, in spite of the mention of these things in the Qur’an. To be honest, I don’t feel comfortable talking to those sorts of psychiatrists.
The psychiatrist being religious was something very important for some (Browning 2003; Gallagher, Wadsworth & Stratton 2002). These religious individuals would feel they were more understood when their psychiatrist was religious. Nour, one of the female participants, said:
I feel comfortable with my psychiatrist. He is religious and a strong believer, I mean. You would feel comfortable dealing with someone who acknowledges the religion’s points of views.
241 Psychiatrists were seen as being against the accessing of traditional healers generally. A male participant said:
They do not encourage visits to Sheikhs, they would say that these sort of things are lies and fraud. They would tell you it is better to visit a psychiatrist.
Religiosity was not the only measure of proficiency for some. In addition to religiosity, it was important for a psychiatrist to have the proper skills. Religiosity is as important as competency in the area of psychiatry. Hannan, one of the female participants, said:
My psychiatrist is great. He is not only religious but also competent.
Psychiatry in the West
There were comparisons by participants between psychiatry in Jordan and in the West. Some of these comparisons were based on real experiences and others had emerged from exposure to the media. Services in the West were seen to be more efficient and advanced. This is noted by Fanon (1986) who suggests one of the characteristics of colonization is that the colonized consider themselves inferior to the colonizer.
Firas compared mental health services in the USA, were he had lived for some time, and those in Jordan, saying:
The psychiatrist’s treatment here is different than in the US. In the US, I know that there are two parts of treatment. One with medication and the other is the talk therapy. I also know that the psychiatrist is possibly trained with specific courses to be able to talk with patients if the time allowed them. This approach was great but I couldn’t afford the treatment over there. I had to return.
Nida, a female participant, said:
242 The treatment is more advanced in the western countries than it is the case with us.
Jameel, one of the male participants, said:
My brother lives in Europe. He told me that it is much easier to get treatment for your psychological problems than here. He told me that psychological services are more advanced over there.
Family’s view of psychiatry
Some of participants accessed the clinic with the support of family members or friends. The accessing of the mental health clinic was strongly encouraged in some cases by family members. This is indicated by Agbayani-Siewert, Takeuchi and Pangan (1999). Other participants, however, accessed the mental health clinic despite the objections and the disapproval of family members. Some indicated that none or few of their family members or friends were informed about their accessing mental health services. Some participants indicated that some family members did not approve of visiting a psychiatrist or taking medication for various reasons. These family members may, however, have changed their opinion after they noticed some positive results.
Nour, one of the female participants, said:
My mother is the only one who cares about me. But my mother doesn’t believe at all in psychiatry or even in medication. She is not happy with me coming here at all, but she doesn’t prevent me from coming here. I come here in spite of her doubts. She thinks medications harm the body. But last time when I was improving with the medication she said that the medication was great.
The objection of family members to participants accessing the mental health clinic was based on the idea that there was no psychological problem as such. Amal, another young female participant, said:
243 My father and family objected to me coming here, they said: ‘You don’t have any problem.’ They came with me to the first visit to the psychiatrist. They came with me in spite of not believing in the necessity of the visit. They just came because I insisted in seeing a psychiatrist for my anxiety. They are still not convinced with the whole subject altogether.
On the other hand, there were some family members who supported participants’ access of the mental health clinic. Some initiated the suggestion that the participant accessed the clinic to cope with their mental health problem. Muhseen, one of the male participants, said:
My brother and my eldest sister supported me. They said medicine is a science and that’s why there are universities and qualifications for that. It is impossible for someone to study the subject without any benefit. They said it is normal to use medicine.
Hussain, another male participant, said:
My friend, the one accompanying me today, told me that he wanted to take me to a psychiatrist a long time ago. He encouraged me to come here.
Participants’ visits were something kept confidential. Family members and friends were not informed. Firas, another male participants, said:
I do not want to tell them. I don’t see any need of telling them. It wouldn’t benefit me.
Some developed a trust in a psychiatrist which was based on other people’s opinion and experiences. Hannan, one of the female participants talked about how she was encouraged to access the clinic by people who had experience with the psychiatrist.
People had a good experience with him. I mean when people have a good experience and they are cured your trust will increase in psychiatry.
244 Other mental health professionals
A small number of male and female participants talked about the role of other mental health professionals. There was a lack of familiarity with the role of other services. Some viewed other mental health professionals roles as being important, as these responded to their needs.
Some considered talk therapy was as important as the taking of medication. Hannan said:
In my case I need medication; I need something to calm me down. I also need to talk to someone to vent my feelings. I want to get what is inside my heart out. I wish there were some people in the clinic that could listen to you. The psychiatrist would listen to summaries, but you need to have the chance to talk more about the psychological problems.
The counsellor was seen as an educator, and their support was seen by many participants as more important than medication. Trust is essential in the relationship with the counsellor. Amal, a young female participant, talked about her disappointment at not finding enough counselling services at the clinic. She told me:
When I actually first came here, I was expecting to get talk therapy for my problems. I didn’t expect medication for my psychological problems.
Nour, another female participant, said:
Sometimes the person might benefit from a kind and trustworthy person more than benefiting from medication. It is not better than medication but it might help a lot. Especially, when you are dealing with a knowledgeable professional who understands what you are saying. You might feel relieved on that subject even though you are not getting any medication.
245 The role of counselling was seen as an alternative to the support of family members. The counsellor was considered by some to be more understanding than their family. Firas, one of the male participants, said:
You can’t talk to family. You never know how they would perceive you. They do not always accept what you say.
Some viewed the role of other mental health professionals as not being as significant as the role of the psychiatrist. They believed that therapy was significant only if it is from a medical practitioner, and specifically a psychiatrist.
Muhseen, one of the male participants, compared the role of the psychiatrist to that of other mental health professionals.
I think talking to professionals other than a psychiatrist is wrong. I mean when you talk to the psychiatrist it is different than when you talk to the social worker or psychologist. The psychiatrist is more important.
Burhan, a male participant, considered life experience, more important than professional experience, which other mental health professionals have.
Sorry for saying that, but I think I have more experience in life than the social worker who interviewed me the other day. She is much younger than me.
Most of their participants were not aware of the role of other mental health professionals. They did not have any experience in receiving help from anyone other than psychiatrists. Most of the familiarity with counselling was based on school experiences. Baheera said:
I know social workers are usually present in organizations such as schools or other similar organizations. I haven’t met anyone in relation to my problems yet.
246 A small number of male and female participants said that they were aware of the role of counselling through their having had experiences in the past which required help. Most of these incidents were through school counselling, psychotherapists, or social workers. The participants who had experience of the helping professions were mainly those who used to live in Kuwait.
Mahmoud, one of the male participants, told me:
I know counsellors are usually present in organizations such as schools or similar places. I had an incident with a social worker when I was a student at one of the schools in Kuwait. While at school, I felt like I was suffocating. The social worker called my father and he came with me to talk to my parents. I suspect this is the role of the social worker.
Baheera, another female participant, said:
We used to have social workers at school in Kuwait. I do not know, however, if they have any here.
Another female participant said:
I heard about them in Kuwait. They used to be at my children’s schools. I used to hear about them from my children.
Perception of other mental health professions
The role of the counsellor was seen as being supportive for individuals with mental health problems. One of the female participants told me how she considered the role of the counsellor:
Counsellors are supposed to understand the circumstances of the sick, his personal qualities. They supposedly liaise between the sick person and the psychiatrist, for example.
247 Amal, one of female participants, commented on a session with a psychologist at the clinic:
I had a session with the psychologist, when I first came here. My parents attended with me at the start of the session. Towards the end of the session, the psychologist met with me on my own. He was very kind but didn’t quite help me. He didn’t quite tell me what I needed to do, or how to solve my problems.
Most participants only accessed the help of the psychiatrists, and this access was mainly to get medication to deal with their problem. Many had not had any experiences with other mental health professionals. Their experience with the psychiatrist was satisfactory in some cases, as psychiatrists provided support and explanations. Some, however, talked about psychiatrists not meeting their expectations. They wanted more support in making decisions about their lives, to be able to disclose some of their worries, and to share some of their religious experiences and perceptions, without being judged.
Some participants still accessed the clinic even though they did not consider the psychological problem to be a mental health problem. They might have used a different name for it – stress, frustration, or some physical term – but they still asked for the support of mental health professionals and psychiatrists in particular. This was in order to get medication to help them cope with the problem. Some talked about how the lacking by acknowledgment of religiosity of mental health professionals made them seek the help of traditional healing. Most of the time this happened, without these experiences being shared with psychiatrists.
Part Four: Seeking Social Support
Participants discussed a variety of social help-seeking approaches which they used in order to cope with their mental health problems. Some of these were family support, while others were coping activities. Most of the support was from immediate family members and not from the extended family as the experience of
248 the mental health problem was kept confidential in most cases. Some participants talked about not even getting support from close family members as they had kept their experience private. These experiences are different from what some of the literature on Arabic and Muslim cultures indicates. For example, Al-Krenawi indicates that family and social support is considered an important part of the help- seeking approaches of Muslim Arab cultures (Al-Krenawi & Graham 2003).
Participants talked about how they perceived the seeking of support from those around them. Some indicated that they looked for and received the help of family members or a friend. The family generally provides various types and levels of assistance. Some, on the other hand, felt they were not getting any support and felt lonely.
A number of the participants indicated that social support was an important part of their coping with mental health problems. Conversely, some discussed the negative impact of family on their coping with mental health problems. While some talked about socializing as a coping mechanism, others considered their isolation was their coping mechanism. Many considered that they had the support at least one family member, spouse, or friend. Male participants generally talked about getting more support than female participants. Male participants got more support from wives, mothers, and other relatives. Female participants talked more about not being supported by family members: not feeling able to express or to talk about their difficulties was one of the main causes of suffering for these female participants. The fact that they were not getting psychological support was seen by some females as another sort of suffering independent of the fact that they were suffering from a mental health problem.
Nour, one of the female participants, said:
249 I am by myself. No one supports me. I am not getting that much support. I suffer from not having psychological support. I can’t turn to any of my family for help. They do not understand.
Amal, another young female participant, told me:
My parents do not understand my problems. I never share anything with them.
The perception of participants about family support varied. Most talked about their loneliness and that they were not getting the support they needed.
Other social support might be provided by a sibling. Muhseen talked about the support he was getting from his family:
All my brothers and sisters support me. I mean they always encourage me and support me. Yes, they love me, and they try not to hurt my feelings at all.
Parental support
More female participants than male participants talked about receiving support from their father. No male participants talked about the support from their father. While some female participants discussed that the strict approaches of fathers as one of the causes of their mental health problems, the ones who did not see the father as one of causes of their problem seemed to consider their father as the main support. This support was given by providing advice, understanding, or financial assistance.
The male participants did not mention the role of their father in providing support. This was probably related to the fact that most male participants’ fathers were not alive, or just because they did not play an active role in supporting their sons when they were affected by mental health problems. Firas, one of the male participants, talked about not receiving support from his father. The role of the father was more harmful than supportive.
250 I told my father about my psychological problems; I didn’t want to tell him. I would rather he didn’t know. He wasn’t helpful. On the contrary he was of more harm.
He further said:
The only support I get from my father is financial support for the cost of treatment, when I was getting the treatment at a private clinic. I wasn’t working back then and I needed someone to fund and to cover the expensive treatment and medication. I needed him to pay for me, but he is only providing financial support. Nothing else.
For female participants, the father in some cases was more understanding and supportive than the rest of the family. Nida compared her relationship with her father and her mother:
My father used to be the closest one to me. He died five years ago. I miss his support. I do not have the same relationship with my mother.
Rania discussed the same notion:
After the divorce my father tried to do his best to help me to overcome my problems.
Most female and male participants considered their mothers to be a source of support. Nour considered her mother as the only support for her mental health problems:
My mother is the only one who cares about me. My brother and sister do not care about me.
While describing her father as supportive, Rania considered her mother as being over-protective:
My mother is supporting me but sometimes it is a killing love. She interferes with everything.
251 Family members might minimize the problem. This was often seen as a strategy to help individuals with mental health problems cope with their problems. The mental health problem was often seen as not being justified as children had not been through enough in life to cause them distress. Amal, one of the young female participants, stated:
I tell my mother ‘You are my mother and you are supposed to be more understanding of my problems.’ She answers me: ‘It is right. But are you still young and havn’t been through much in life. What pain have you experienced to suffer from distress? You are supposed to thank God.’
Mothers might also not be well informed about the problem. They might not understand the nature of the illness. Fouad, one of the male participants, said:
My mother is an old lady. She can’t comprehend the meaning of psychological problems.
On the other hand, some female participants considered mothers to have a negative influence and not to be supportive of their daughters. Some considered their relationship with their mother as a contributor to the intensity of their mental health problems. Nida, one of the female participants, said:
My mother is sort of a controlling woman. She would magnify any small word. I don’t get along with her.
Hussain, one of the male participants, said also discussed his lack of support:
I do not get along with my mother or father. My mother doesn’t accept me. She prefers my other siblings. She doesn’t understand I need to be left alone sometimes.
Partner Support
Most female participants who were married considered their husbands to be supportive of them. Their husbands played a vital role in encouraging them to get
252 treatment and support to cope with their mental health problems. The two female participants who had lost their husbands also talked about positive experiences. They missed this support after they had lost their husbands.
Baheera, reported:
My husband and my children are supportive to me. My husband is great and he is very understanding.
The support is mainly based on the religious perception of pain. The husband encourages the wife by sharing her perception of mental health problems, such as seeing the mental health problem as being a trial or that there would be an end to pain, and that everything is Allah’s will. Maryam reflected on this concept by saying:
My husband is the best thing in my life. My husband says to me ‘God created you and he would never forget you. God is the one who put the problem on you and he is the one who is going take it away form you.’ He also said ‘It is a trial from God.’
She further reflected:
My husband encourages me to come and to get treatment. He is generous with me and always provides me with the cost of the medication. I wanted to stop the treatment because of our financial situation but he said ‘No, even if I had to sell all the furniture, you are still getting treatment.’ My husband is with me for better or worse. He is trying hard.
A couple of female participants said that they were not getting support from their husbands. These negative experiences with their husbands were based on the fact that the husband was not understanding of the wife’s psychological problems. Some had not told their husbands that they were getting help from the psychiatric clinic because of fear that he might not accept the idea or that he might judge them. Hannan told me:
253 I would rather not to share my psychological problem with my husband. No, I don’t want that to happen. I would love if my husband was a caring husband. I wish he could understand my pain when I talk to him. I mean I tried many times to talk to him about my problems but he wasn’t responsive.
All married male participants talked about the main support from their wives. Their wives played an important role in providing support and in their continuing to get treatment. Mahmoud said
The main support I am getting is from my wife. I feel that God blessed me with some things, especially my wife, who is very supportive of me. She is very tolerant of me when I am feeling down. She understands my problem.
Other sources of support
A large number of participants discussed engaging in social activities as one of the coping mechanisms they used to deal with their mental health problems. Mahmoud, one of the male participants, said:
I used to notice one thing only, that’s when the things are too intense; I tend to occupy myself with anything. I would go for visits I would visit my sister. I would do any thing to keep myself busy so the thought wouldn’t come back again.
Sami, one of the male participants, said:
Whatever happens to me I try not to think about it. I try to occupy myself to forget. I would go to visit my friends, or do some gardening. I try not to keep thinking about the problem.
A female participant said:
I like to go out. I do not stay home when I am feeling bad. I try to be with people to not think about my problems.
254 On the other hand, isolation and not mixing with others was considered a way of coping by some. Jameel, one of the male participants, said:
I mean I like to be on my own. I like to be alone. I wanted to isolate myself, I mean because of the problem I am facing I started to like to be away from others. I have friends. But I sort of like to be alone. I don’t talk to my friends about that sort of problem.
Some participants used isolation as a coping mechanism at the start of their disorder. A male participant said:
I mean I stayed home and isolated myself. I was feeling afraid, depressed, and anxious.
Isolating the self might be due to feelings of guilt that the individual might cause stress to a close family member. Fouad, one of the male participants, said:
When I used to feel stressed I would prefer to be on my own. I would avoid talking to anyone, especially to my mother, because she would feel sad. I prefer to keep things to myself to avoid troubling anyone.
In summary, participants sought social support mainly from close family, extended family, or friends. Most participants talked about getting support from their immediate family members. They also explained that they were cautious about disclosing anything about their psychological problems to extended family because of their fear of being stigmatized. Some talked about being lonely and not getting support from even their immediate family. This applied particularly to single male participants and divorced female participants.
Summary
In this chapter I have explored help-seeking as it represented in the Qur’an and the Hadith and as it was evidenced in interviews with participants. The help-seeking process amongst these Muslim individuals is based on their spiritual experience,
255 which is based on religious philosophy and teachings, although the nature of this spiritual experience is highly individualistic. It is evident that religion plays a very large part in the experiences of help-seeking amongst the Muslim people I interviewed, and this mediates their approaches to traditional healing, their seeking of professional help and their attempts to obtain social support. In the next and final chapter I conclude my research journey.
256 CHAPTER EIGHT
CONCLUSION
The aim of this research was to develop the knowledge base about Islam and mental health. In order to do this, I interviewed a cohort of Jordanian individuals who were diagnosed with mental health problems, and integrated their observations with an analysis of the main sources of Islamic philosophy: the Qur’an and the two books of the Hadith.
The research journey was an extremely rewarding experience. Learning and conducting the research has been a source of deep contentment and constant discovery for me. It was a spiritual experience, apart from one having academic value. At the start of the research I intended to investigate Jordanian individuals’ perceptions of their mental health problems. I wanted to understand how people in Jordan – who represent just one group of Islamic people – conceptualized their psychological distress. My original intention was to explore the general perceptions of individuals accessing the National Centre of Mental Health in Amman, Jordan. However, after a preliminary analysis of the data, and as the research developed and evolved and as participants discussed their experiences and understanding, the focus grew to include the exploration of religion and the perception of mental health problems in Islam itself. I started to think about the need to understand religion and the perceptions of mental health problems within Islam. I wanted to know how mental health problems are perceived by traditional Islam.
I conducted the research in Jordan where I had worked in the mental health field as a social worker, and as an educator for seven years prior to migrating to Australia. I decided to explore the nexus of mental health and Islam after being exposed to different experiences of mental health understanding and service delivery in Australia. These more recent experiences in Australia enriched my understanding
257 and provoked my curiosity about how mental health practitioners understood the role of culture and religion in their practice and how these were relevant in a western medical context. As I explored the scholarship on this matter, it was a apparent that my interest spanned a number of important research questions. As I commenced conceptualizing this research, the central question that emerged was: How do Jordanian Muslims with mental health problems perceive their mental health problems?
It was clearly not possible to sample across all Islamic societies and so my research focused on one Islamic society with which I was familiar and in which I had been employed in mental health services. Twenty semi-structured interviews were conducted to gather data from Jordanian individuals who were being treated for mental health problems at the National Centre of Mental Health in Jordan. Conducting the research in Jordan was an exciting and stimulating experience, full of revelations. I learnt from each one of the participants, considering them the experts who shared their experiences with me, the learner. I was cognisant of the fact that there is always constant tension in maintaining this position with participants, where different levels of power, genders, and social backgrounds potentially interfere in any interaction and the interpretation of such interviews.
The research focus was refined as the research progressed. The interviews with participants and my ongoing reading of related literature suggested that religion could be seen to be one of the most vital aspects of culture in relation to understanding mental health problems. The primary finding of the research is that amongst a cohort of Muslim respondents, religious beliefs have a pivotal place in their interpretation of their mental heath problems. This was manifest in the direct comments of participants, as well as in their expressions and explanations. The importance of religion was expressed by each participant, regardless of gender, level of education, or social background. Participants talked about religion, whether they identified themselves as being very religious, moderately religious, or even if they had doubts about their religious beliefs. I became increasingly aware
258 that the centrality of religion might be even more important when dealing with non-western societies, where religion is often considered a way of life.
I had originally expected to interview more than twenty people, but it became apparent after I had undertaken twenty interviews that no new themes were emerging and that I had achieved what Minichiello (1995) and others call saturation of the data. I also realized at this point that I needed to undertake a thorough textual analysis of the Qur’an and the Hadith. This led me to think about another dimension and to enter into another layer of exploration, which was to engage in an analysis of Islam itself. This was to understand the following question: How are mental health problems perceived in the main Islamic texts?
I undertook an analysis of the main source for the Islamic religion, the Qur’an, the holy book for Islam. In addition, I explored the prophetic traditions, which are contained in the Sahih Bukhari and the Sahih Muslim. These are the main books of the Hadith, which for most Muslims represent a secondary source of understanding of the Islamic tradition.
The research involving the analysis of the texts was no less exciting than the experience of interviewing the participants. At the beginning of the exploration I was anxious; I was aware that this would not be an easy subject to research. I was aware that my field of research was social science rather than theology and that I could not claim the advanced religious knowledge that some might consider I needed to deeply explore the subject. On the other hand, what I was seeking was an accessible interpretation of the Islamic texts – an understanding that could be reached by anyone interested in exploring the subject – for the very practical reasons that underpinned the research, namely to develop professional knowledge for mental health practice.
259 My intention was to search for, locate, and gather the themes around the subject of mental health in the texts. In spite of my familiarity with both the subject of mental health problems and the Islamic religion, I was surprised to find so many themes related to the perception of mental health problems.
Although my comprehensive search and analysis of literature included theological literature, the first stage of the research involved a review of the literature on professional practice at the intersection of mental health, culture, and religion. Given my long period of involvement in practising and teaching in mental health and my familiarity with Jordanian culture and the Muslim religion, I believe that I was in an excellent position to undertake research at the nexus between culture, the Islamic religion and mental health. However, my initial readings identified many gaps in the professional arena.
A core theme emerged as I explored the literature and this was the problem of defining this area bounded by culture, religion, and mental health. The field is variously called ‘cross-cultural psychiatry’ or ‘comparative psychiatry’ or ‘transcultural psychiatry’. I adopted the term ‘cultural mental health’ as an alternative to these terms, because in large part this latter term strongly proclaims that the field includes not only psychiatry, but also other disciplines such as anthropology, cross-cultural psychology (Berry, Poortinga, Pandey 1997b; Tseng 2001b), nursing (Leininger 1984), sociology (Aneshensel & Phelan 1999b), and social work (Al-Krenawi & Graham 2000b). Most of these authors have urged more co-operation among disciplines in order to have a more collective understanding of traditional cultures and their relevance to mental health assessment and treatment. In using the term mental health rather than psychiatry, I was in some ways responding to the call of many scholars to develop a more inclusive scholarship and practice to respond to and include other areas such as domestic violence, poverty, children’s mental health, terrorism, substance abuse, and women’s issues, in what otherwise was and is a more limited domain of practice. These latter problems are seen by many contemporary scholars to be
260 important ones to incorporate as we deal with issues in a globalized world. I accept the argument that they must be taken into account by mental health professionals.
The second definitional issue that confronted me early in the research was that of the distinction between religion and spirituality. I found that this distinction is not clearly articulated within the scholarly literature. The sharp division and the separation between the spiritual and the religious appears to be a western distinction and was not evident until the early 1990s. Although the concept of spirituality appears in much of the contemporary western literature, it is not a concept that is easily distinguishable within Muslim tradition. Drawing the line between religion and spirituality in Islam is virtually impossible; therefore, I chose the term religion to include spirituality and religiosity. I have used the term religion in a broad sense, to include the spiritual aspects, the sum of beliefs, feelings, relationships, acts and symbols that comprise Islam.
What also became clear from the research is that the religious experience in Islam, as indicated by participants, is a unique experience for every individual. It is, according to them, an internal, confidential experience – each person thinks about, perceives and encounters the experience individually – even within a collective religious and cultural community, group or society, in which all share the same religious beliefs. Islamic philosophy encourages individual responsibility, as Smith (1999 p. 240) has noted: ‘We are struck by the stress the Qur’an places on the self’s individuality: it is uniqueness and the responsibility that develops on it alone.’
The participants demonstrated that their religious experience had also changed in its level of intensity and in the way that values and traditions were followed over time and in relation to interaction with others who might have the same or different beliefs.
261 This research with Muslim patients attending a mental health clinic in Jordan showed very clearly the centrality of religion to the sense these people made of their mental health problems – and it provides an important insight about the significance of religion to the conceptualization of these people of their mental health problems, the causes of these problems and their help-seeking endeavours.
Also, clear from this research is the fact that the Islamic religious texts provide an opportunity to gain a significant insight into the ways that religious philosophy can influence Islamic individuals’ perceptions of mental health problems. Further research would need to be undertaken to ascertain whether religious texts of other faiths would have an equivalent role.
What is important to note is that Islamic texts are part of the daily life of most Muslim people. They use verses from the Qur’an in their daily conversations, to help them to solve their problems. Some read the Qur’an frequently as this is also commanded by the Islamic religion. As participants said, the Qur’an and the Hadith are part of the school curriculum, the subject of discussions on many educational channels, and the basis for and part of the daily conversations of many people. This means that the Qur’an and the Hadith are important reference points for understanding all problems, including mental health problems – their causes as well as the mechanisms by which people cope with them.
These causes and coping mechanisms are itemized in this thesis and help to highlight two important factors. Firstly, the extent of the reference to mental health problems in the Qur’an and the Hadith, which demonstrates the importance of any mental health professional appreciating their potential significance when they are working with Muslim people. Secondly, they add weight to Kleinman’s Explanatory Model insofar as they invite professionals to understand how people explain their mental health problems and experiences. The findings of this research emphasize the ongoing relevance of Kleinman’s Explanatory model. This research highlights the continuing importance of understanding how people with a mental
262 illness conceptualize and make sense of their lives in general and their mental health problems in particular.
The comprehensive analysis of the Qur’an and the Hadith provided a wealth of data which may assist mental health professionals to understand and assist people from an Islamic faith to conceptualize and deal with their mental health problems. The analysis shows the powerful influence of the Islamic texts on the perceptions of mental health problems of participants. Regardless of their religious orientation or the intensity of their beliefs, all participants paid attention to religious issues. Participants expressed these concepts through idiomatic expressions or by reciting verses from the Qur’an and the Hadith.
All of the participants volunteered information and ideas about the role of religion in their mental health problems. Even the very small number of participants who indicated that they had doubts about religion expressed strong opinions about the role of religion in relation to mental health. Religious beliefs dominated their discussions about the cause and path of their experience of mental health problems. Both male and female participants were preoccupied with the subject of religion and nearly all of them indicated that their religion assisted them in coping with their mental health problems.
Male and female participants discussed different levels of religiosity. Both females and males talked about not practising their religion, and some males expressed feelings of uncertainty about their religious beliefs. Whatever the religious orientation of participants, they still talked about religion. While some talked about feeling content with their religious beliefs and practices, others expressed feelings of guilt for not practicing religion as they thought they should. They talked about being Mumeneen (believers) and about their commitment to not sinning or harming others. Some, however, felt unable to keep up the practice of religion because of their being lazy. Some were concerned that their failure to carry out their religious practices might be due to their psychological problems. Even these participants
263 who doubted their religion still talked about their ideas and attitudes toward religion and religious people. It was clear that religion is a vital part of their culture and central to their understanding. The subject of religion was even mentioned by the two male participants who identified themselves as being non- believers.
Participants also discussed how they defined their psychological problems. Some considered the problem to be a mental health problem. Others considered their problem to be physical, behavioural, or social – but not psychological. Many highlighted the stigmatization of psychological disorders. This is possibly one of the reasons why some people considered their problem not to be a psychological one.
Two main themes about the assessment and treatment of mental health problems emerged from the review of literature and the analysis of data. The first theme relates to causation of mental health problems and the second one to the help- seeking approaches undertaken.
Themes related to causation were discussed in Chapter Six. The analysis showed a significant complexity in the perceptions of causation, mainly around the notions of Allah and religiosity. The perceptions of causation contained in Islamic texts and indicated by participants tended to be multiple. The variety of attributions of causality provided individuals with a richness of options which might suit their stage of life. However, all of these causations were placed within the context of the relationship with Allah and Allah’s will. Causation could be attributed to not safeguarding Allah’s commands, to Qadar, to a trial, or to blessing (even to gaining rewards for accepting a condition or to purifying a person from sins). Other secondary causations of mental health problems found were the effect of the spiritual world and socio-political elements. Most participants attributed more than one cause to their mental health problems – often this attribution included primary and secondary levels. For example, some people attributed causality to both
264 punishment and guilt. Also, some people combined socio-political causal factors with Allah’s will. Other participants saw a combined causality in domestic violence, the evil eye, and a ‘trial’; still others attributed the cause to their strict upbringing, unemployment, and punishment for wrongdoing. In summary, the attribution of causation ranged from spiritual agents to social and political ones. Yet as a starting point, most participants placed the cause of their mental health problem within Allah’s will, adding other secondary causes to this.
The significance of religious beliefs also emerged around the help-seeking approaches explained by participants and in the Islamic texts. These themes were explored in detail in Chapter Seven. My analysis of the data is that help-seeking in Islam is conceptualized at two levels: the spiritual and the practical. The spiritual level is the more basic and it underpins the help-seeking journey and gives context to practical measures. The basic spiritual elements are supposed to have a calming and healing effect in their own right. Strategies for dealing with mental health problems in Islam vary, as they are likely to do in all societies. However, in Islam, all healing is in Allah’s hands. As with causation, the supreme context is in the relationship with Allah. The data are clear – illness, like healing, comes from God.
Added to this is the more practical level – namely, looking for practical sources for help is also important in Islam. Indeed, it became apparent from the data that looking for help is an obligation for Muslim people. Many participants talked about the fact that failing to seek help might harm the self, which they understood to be a sin. The practical searches for healing that were used by participants and acknowledged in the texts included traditional healing, professional help, and social support.
It is interesting that there was not always a link made by participants between their perceptions of the cause of their mental health problems and the ways in which they sought help. For example, individuals who thought the cause of their problems
265 was physical, social, political, or jinn, sorcery or the evil eye, might still access the clinic in order to get medication and support.
An observation made by the majority of participants concerned the superiority of the West in its delivery of mental health services. Yet, at the same time they were highly critical of mental health service delivery in Jordan – a service delivery system firmly established on western models of thinking. Participants talked about the image of mental health professionals in the West that they had developed from their own experiences overseas or the experiences of family overseas or from the media. On the one hand, they criticized mental health professions which are based on western religions and philosophies for not being responsive to their needs and saw mental health professionals as being overly scientific. There was a general view that, by applying a scientific model, professionals were not giving individuals with mental health problems sufficient opportunity or encouragement to talk about their way of understanding their experience. It is interesting that this perception of the failure of professionals was the same regardless of whether the professionals shared participants’ religion or nationality.
On the other hand, participants looked to the West for ideas for services, seeing the West as having a more advanced, humane and sophisticated approach and better service provision to individuals with mental health problems. Post-colonial theorists such as Edward Said, Franz Fanon, and Homi Bhabha, have of course grappled with the issues of western supremacy, and focused on the exploration and examination of the dominant notion of European supremacy in relation to non- European cultures and societies. They have noted the collision of ideas between those whom they call the colonizer and the colonized.
However, my analysis suggests that this dichotomy is more apparent than real. Participants did not want to eschew the West, but they wanted mental health professionals to acknowledge and to allow the incorporation of their religion and culture into the helping relationship. This research suggests that this cohort of
266 Muslims wished for a mental health profession that is based not only on western approaches, but also having a strong connection with local cultural elements, including religion. This hoped-for approach may represent the reality of the dynamic changes in society that have resulted from globalization and the consequent hybridity of the identities that have developed amongst nations. What is apparent from this research is the need for health professionals in post-colonial societies to respond to mental health problems in ways that recognize complexity: that take into account the effects of globalization at the same time as being sensitive to the idiosyncrasies of local cultures and religions. In other words, what is evident is the need for helping approaches which balance modern approaches with traditional religious approaches.
The research data suggest that it is very likely that there continues to be some significant gaps in how mental health professionals deal with religiosity amongst people of a Muslim faith. In this respect the research supports the findings of scholars such as Larson (1998) and Koenig (1998), who suggest that mental health professionals have avoided the subject of religion for too long, and still have a long way to go. I would argue that by ignoring the importance of religion in non- western cultures, mental health professionals are at risk of being seen to be continuing to impose their own perceptions of mental health problems – perceptions that derive explicitly from a western based model that has been noted to exclude religion.
Although I was only able to interview a cohort of Islamic people from one culture and society, the data they provided presented a very coherent picture of reliance on religion in both the assessment of the causation of problems and the approach to attempts to get help. It would be interesting to use this research to explore its relevance to other Islamic societies and to the experience of Islamic people who live in western societies.
267 The analysis of the Islamic texts provides a benchmark for further study. I hope that scholars can capitalize on this research and integrate it into the development of professional practice in mental health. My experience as a mental health practitioner in both Australia and Jordan, coupled with my reading, suggested that there was a deficit in professional understanding in both societies about the relevance of the uncomfortable fit between western medical models of thinking and the idiosyncrasies of cultural and religious beliefs. The research has confirmed my disquiet and hopefully added to the scholarship that might enable more understanding of how to move forward in cultural mental health endeavours.
Apparent from this research is the importance of addressing religion in clinical settings. What is evident is that such inclusion can enable practitioners to strive for individual interpretations and thus empower people who in all likelihood are feeling intensely powerless (Kleinman 1980). In noting the significance of these efforts, it is also apparent that addressing religion and spirituality is not an easy task for mental health professionals, especially given the variations in religion and spiritual orientation even within a single religion or society. In this research I addressed the perceptions of one cohort of Islamic people. Although the knowledge I have gained is immense, the task of conveying this to busy professionals feels daunting – and there are a large number of religions and variations of religious belief. Added to this very practical problem is that many mental health professionals are likely to have a very different religion to the people they are treating, or they may have an atheistic approach to life.
Perhaps, as Kleinman and Benson (2006) so cogently argue in their article, Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix it, what mental health professionals need to take into consideration when dealing with individuals with mental health problems in clinical or research settings is that it is the individuals’ right to have their mental health problem dealt with within the context of culture and religion. Kleinman and Benson (2006) add that mental health professionals need to listen to the stories these individuals tell, and that they
268 need training to be able to deal with different levels and orientations of individuals with mental health problems. Allowing the discussion of religious orientations and spirituality will enhance practitioners’ and researchers’ relationships with these individuals. It will allow other important dimensions of thinking and perceptions which might influence the professional relationship to be explored. This is vital when dealing with individuals from Muslim backgrounds, where religion is considered an important part of the culture.
I acknowledge the complications of presenting a hard-and-fast rule for dealing with cultural and religious issues. I also acknowledge the diversity of the cultural backgrounds of the colonised within even one community, as post-colonial theories tell us (Ashcroft, Griffiths & Tiffin 2006), and as asserted by Kleinman and Benson (2006) in their discussion of the Explanatory Model. However, something which clearly emerged from the analysis of the participants’ conversations was that they not only have rich perceptions in relation to their mental health problems, but they are keen to tell their stories and to share these perceptions with mental health professionals. I believe there is a need to research and develop better practical methods for mental health practitioners to apply in the clinical settings.
This research does not provide answers to the many practical questions that can and will need to be addressed about how to improve cultural competences amongst mental health professionals in societies that embrace religious beliefs. What it does is add weight to the evidence that such competences are essential. The very practical questions will only be answered as research findings such as these are disseminated and discussed. It is very clear that more research is necessary into the importance of personal religious beliefs such those in Islam. Research needs to focus on subjects which can assist mental health professionals in dealing with the religious element, as one of the most important elements of their culture. This thesis offers some delineations of Islamic culture, which I hope will contribute to the understanding of some aspects of the Islamic religion in relation to mental health problems, and how individuals from one culture might be influenced by
269 these religious elements in their thinking and perceiving of their psychological problems.
There is growing interest about cultural and religious factors among scholars and professionals. There is also growing awareness among members of the community of the importance of having their mental health needs met. This research provides one further step in what Kleinman calls for, which is negotiation and compromise to reduce the gap between the explanatory model of mental health professionals and that of the individuals with mental health problems.
270
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292 Walsh, M. 2003, 'Teaching Qualitative Analysis Using NVivo Software', The Qualitative Analysis Using QSR NVivo, vol. 8, no. 2, pp. 251-256. Weaver, A. J., Kline, A. E., Samford, J. A., et al. 1998, 'Is religion taboo in psychology? A systematic analysis of research on religion in seven major American Psychological Association journals: 1991-1994', Journal of Psychology & Christianity, vol. 17, no. 3, pp. 220-232. Wig, N. N. 1999, 'Mental health and spiritual values: A view from the East', International Review of Psychiatry, vol. 11, no. 2-3, pp. 92-96. Williams, B. & Healy, D. 2001, 'Perceptions of illness causation among new referrals to a community mental health team: ‘Explanatory model’ or ‘exploratory map’?' Social Science & Medicine, vol. 53, no. 4, pp. 465-476. Yarkindi, H. b. H. 2000, al-Sihhah al-nafsiyah fi al-mafhum al-Islami wa-dirasat nafsiyah ukhrá, al-Tab‘ah 1. edn, Dar ‘Alam al-Kutub, al-Riyad. Yegenoglu, M. 1998, Colonial fantasies : towards a feminist reading of Orientalism, Cambridge University Press, Cambridge, United Kingdom ; New York. Yi, S. H. & Tidwell, R. 2005, 'Adult Korean Americans: Their Attitudes Toward Seeking Professional Counseling Services', Community Mental Health Journal Vol 41(5) Oct 2005, 571-580. Young, J., Bailey, G. & Rycroft, P. 2004, 'Family Grief and Mental Health: A Systemic, Contextual and Compassionate Analysis', Australian and New Zealand Journal of Family Therapy Vol 25(4) Dec 2004, 188-197. Youssef, J. & Deane, F. P. 2006, 'Factors influencing mental-health help-seeking in Arabic-speaking communities in Sydney, Australia', Mental Health, Religion & Culture, vol. 9, no. 1, pp. 43-66. Zinnbauer, B. J., Pargament, K. I., Cole, B., et al. 1997, 'Religion and spirituality: Unfuzzying the fuzzy', Journal for the Scientific Study of Religion, vol. 36, no. 4, pp. 549-564. Zlatanovic, L. 1998, 'Transcultural Psychiatry: Old and New Challenges', Sociologija, vol. 40, no. 4, pp. 635-640.
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APPENDICES
294
Appendix 1: Ethical Approval
295
296 Appendix 2: Information Sheet (English)
The University of Western Australia Telephone + 61 8 9380 3838 Facsimile + 61 8 9380 1380 Crawley, Western Australia 6009
Department of Social Work & Social Policy Telephone +61 8 9380 2993 Facsimile +61 8 9380 1070 Crawley Western Australia 6009
Research Title: Cross-cultural Mental Health: A study of Attitudes and Perceptions of Mental Health Problems in Arabic/ Jordanian Cultures.
I am seeking your assistance in participating in research which is examining attitudes and perceptions of people experiencing mental health problems. Your involvement in the research would mean participating in an interview with a researcher, Nada Eltaiba, who is a PhD student at this university. The interview will take approximately one hour. The interview will be in conversation style and you will be asked about your views about mental illness.
The study aims to provide mental health professionals with a better understanding of Arabic and Islamic cultures. It will assist mental health professionals in recognising the role of traditional healing, and the role of the family in dealing with people with mental health problems. In addition to this the research aims to generate a better understanding of the patient’s expectations of mental health professions and services and the role of mental health professionals.
You can decide whether or not you wish to be involved in this research and if you agree to participate and you become uncomfortable with the process, you have the full right to end the interview and withdraw from the research at any time without the need for justification.
The researcher is willing to answer any question related to the research or the interviewing process that you may wish to ask. Only with your permission will it be audiotaped so that I can transcribe your responses fully. The records of the interview will be kept confidential and will be kept in a secure locked cupboard. No identifying information from the interviews will be given to any one unless I am required to do so by law.
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Neither your consent nor your refusal to be interviewed will affect the services provided to you by the National Centre of Mental Health. Your participation in this study will not prejudice any right to compensation, which you may have under statute or common law.
Maria Harries (Chief Investigator) Telephone +61 8 9380 2993
The Human Research Ethics Committee at the University of Western Australia requires that all participants are informed that, if they have any complaint regarding the manner, in which a research project is conducted, it may be given to the researcher or, alternatively to the Secretary, Human Research Ethics Committee, Registrar’s Office, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 (telephone number 9380-3703). All study participants will be provided with a copy of the Information Sheet for their personal records.
298 Appendix 3: Information Sheet (Arabic)
The University of Western Australia Telephone + 61 8 9380 3838 Facsimile + 61 8 9380 1380 Crawley, Western Australia 6009
Department of Social Work & Social Policy Telephone +61 8 9380 2993 Facsimile +61 8 9380 1070 Crawley Western Australia 6009
ﺟﺎﻣﻌﺔ ﻏﺮب اﺳﺘﺮاﻟﻴﺎ ﺻﺤﻴﻔﺔ اﻟﻤﻌﻠﻮﻣﺎت
ﻋﻨﻮان اﻟﺒﺤﺚ: اﻟﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ ﺿﻤﻦ اﻟﺤﻀﺎرات اﻟﻤﺘﻌﺪدة: دراﺳﺔ ﻟﻠﻤﻮاﻗﻒ واﻻدراآﺎت ﻟﻤﺸﻜﻼت اﻟﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ ﻓﻲ اﻟﺤﻀﺎرات اﻷردﻧﻴﺔ واﻟﻌﺮﺑﻴﺔ.
أرﺟﻮ ﻣﻨﻚ اﻟﻤﺴﺎﻋﺪة ﺑﺎﻟﻤﺸﺎرآﺔ ﻓﻲ هﺬا اﻟﺒﺤﺚ واﻟﺬي ﻳﺨﺘﺒﺮ ﻣﻮاﻗﻒ وادراآﺎت اﻷﺷﺨﺎص اﻟﺬﻳﻦ ﻳﻌﺎﻧﻮن ﻣﻦ ﺻﻌﻮﺑﺎت ﻧﻔﺴﻴﺔ. ﻣﺸﺎرآﺘﻚ ﻓﻲ اﻟﺒﺤﺚ ﺗﻌﻨﻲ أن ﺗﺘﻢ ﻣﻘﺎﺑﻠﺘﻚ ﻣﻦ ﻗﺒﻞ اﻟﺒﺎﺣﺜﺔ ﻧﺪ ي اﻟﻄﻴﺒﺔ واﻟﺘﻲ ﺗﻘﻮم ﺑﺪراﺳﺔ اﻟﺪآﺘﻮراﻩ ﻓﻲ هﺬﻩ اﻟﺠﺎﻣﻌﺔ. اﻟﻤﻘﺎﺑﻠﺔ ﺗﺴﺘﻐﺮق ﻣﺎ ﻳﻘﺎرب اﻟﺴﺎﻋﺔ. ﺳﺘﺘﺨﺬ اﻟﻤﻘﺎﺑﻠﺔ ﺷﻜﻞ اﻟﻤﺤﺎدﺛﺔ اﻟﻤﺘﺒﺎدﻟﺔ ﺣﻮل ﺁراﺋﻚ ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﺎﻟﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ.
اﻟﺪراﺳﺔ ﺗﻬﺪف إﻟﻰ ﺗﺰوﻳﺪ اﻟﻌﺎﻣﻠﻴﻦ ﻓﻲ ﻣﺠﺎل اﻟﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ ﺑﻔﻬﻢ أﻓﻀﻞ اﻟﺤﻀﺎرات اﻟﻌﺮﺑﻴﺔ واﻹﺳﻼﻣﻴﺔ ﺣﻴﺚ ﺳﺘﺴﺎﻋﺪ اﻟﻌﺎﻣﻠﻴﻦ ﻓﻲ ﻣﺠﺎل اﻟﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ ﻓﻲ اﻟﺘﻌﺮف ﻋﻠﻲ دور اﻟﻄﺐ اﻟﺘﻘﻠﻴﺪي ودور اﻟﻌﺎﺋﻠﺔ ﻓﻲ اﻟﺘﻌﺎﻣﻞ ﻣﻊ اﻟﺸﺨﺺ اﻟﺬي ﻳﻌﺎﻧﻲ ﻣﻦ اﺿﻄﺮاﺑﺎت ﻧﻔﺴﻴﺔ. إﺿﺎﻓﺔ ﻟﺬﻟﻚ ﻓﺎن هﺬا اﻟﺒﺤﺚ ﻳﻬﺪف إﻟﻰ ﻓﻬﻢ وﺗﻮﺿﻴﺢ ﻣﺎ ﻳﻤﻜﻦ أن ﺗﺘﻮﻗﻌﻪ ﻣﻦ اﻟﻤﺘﺨﺼﺼﻴﻦ ﻓﻲ اﻟﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﺄدوارهﻢ وﺧﺪﻣﺎﺗﻬﻢ . .
ان ﻟﻚ اﻟﺤﺮﻳﺔ اﻟﻤﻄﻠﻘﺔ ﻓﻲ اﻟﻤﺸﺎرآﺔ ﻓﻲ هﺬا اﻟﺒﺤﺚ. وإذا واﻓﻘﺖ ﻋﻠﻲ اﻻﺷﺘﺮاك ﺛﻢ أﺻﺒﺤﺖ ﻏﻴﺮ ﻣﺮﺗﺎح ﻷي ﺳﺒﺐ ﻣﻦ اﻷﺳﺒﺎب ﻓﺎن ﻟﻚ اﻟﺤﻖ ﺑﺎن ﺗﻨﻬﻲ اﻟﻤﻘﺎﺑﻠﺔ وان ﺗﻨﺴﺤﺐ ﻣﻨﻬﺎ ﺑﺪون اﻟﺤﺎﺟﺔ إﻟﻲ إﻋﻄﺎء أﻳﺔ ﺗﺒﺮﻳﺮات.
إن اﻟﺒﺎﺣﺜﺔ ﻋﻠﻲ اﺳﺘﻌﺪاد ﺗﺎم ﻟﻸﺟﺎﺑﺔ ﻋﻠﻲ أﻳﺔ ﺗﺴﺎؤﻻت ذات ﻋﻼﻗﺔ ﺑﻤﺠﺎل ﺑﺤﺜﻬﺎ . ﺳﻴﺘﻢ ﺗﺴﺠﻴﻞ اﻟﻤﻘﺎﺑﻠﺔ ﻋﻠﻲ ﺷﺮﻳﻂ وذﻟﻚ ﺑﻌﺪ ﻣﻮاﻓﻘﺘﻚ .ان هﺬا اﻟﺘﺴﺠﻴﻞ ﺳﻴﺴﺎﻋﺪ اﻟﺒﺎﺣﺜﺔ ﻋﻠﻲ ﻧﻘﻞ ﻣﺤﺘﻮﻳﺎت اﻟﻤﻘﺎﺑﻠﺔ ﺑﺸﻜﻞ آﺎﻣﻞ. اﻟﺘﺴﺠﻴﻼت اﻟﺨﺎﺻﺔ ﺑﺎﻟﻤﻘﺎﺑﻼت ﺳﻴﺘﻢ ﺣﻔﻈﻬﺎ ﺑﺴﺮﻳﺔ ﺗﺎﻣﺔ ﻓﻲ ﺧﺰاﻧﺔ ﻣﻐﻠﻘﺔ. ﻟﻦ ﻳﺘﻢ اﻹدﻻء ﺑﺄﻳﺔ ﻣﻌﻠﻮﻣﺎت ﺗﺪل ﻋﻠﻲ ﺷﺨﺼﻴﺘﻚ إﻻ إذا آﺎﻧﺖ اﻟﺒﺎﺣﺜﺔ ﻣﻄﺎﻟﺒﺔ ﺑﻬﺬا ﺑﺸﻜﻞ ﻗﺎﻧﻮﻧﻲ.
ﺳﻮاء ﻗﻤﺖ ﺑﺎﻟﻤﻮاﻓﻘﺔ ﻋﻠﻲ اﻟﻤﻘﺎﺑﻠﺔ أو رﻓﻀﻬﺎ ﻓﺎن هﺬا ﻟﻦ ﻳﺆﺛﺮ ﻋﻠﻲ ﺗﻠﻘﻴﻚ ﻟﻠﺨﺪﻣﺔ ﻣﻦ اﻟﻤﺮآﺰ اﻟﻮﻃﻨﻲ ﻟﻠﺼﺤﺔ اﻟﻨﻔﺴﻴﺔ آﻤﺎ ﻟﻦ ﺗﺆﺛﺮ اﻟﺪراﺳﺔ أﻳﻀﺎ ﻋﻠﻲ ﺣﻘﻮﻗﻚ اﻟﻌﺎﻣﺔ.
ﻣﺎرﻳﺎ هﺎرﻳﺲ (Chief Investigator) Telephone +61 8 9380 2993
299 ﻟﺠﻨﺔ أﺧﻼﻗﻴﺎت اﻟﺒﺤﺚ اﻹﻧﺴﺎﻧﻲ ﻓﻲ ﺟﺎﻣﻌﺔ ﻏﺮب أﺳﺘﺮاﻟﻴﺎ ﺗﺆآﺪ ﺣﻖ آﻞ ﻣﺸﺎرك ﻓﻲ أن ﻳﺘﺼﻞ ﺑﺎﻟﺒﺎﺣﺜﺔ أو ﺑﺴﻜﺮﺗﻴﺮة ﻟﺠﻨﺔ أﺧﻼﻗﻴﺎت اﻟﺒﺤﺚ. ﻓﻲ ﺣﺎﻟﺔ وﺟﻮد أي اﻋﺘﺮاض ﺣﻮل اﻷﺳﻠﻮب اﻟﺬي ﺗﻢ ﻓﻴﻪ اﻟﺒﺤﺚ ﻓﺎن ﻣﻦ اﻟﻤﻤﻜﻦ ﺗﺴﻠﻴﻢ ﻣﻼﺣﻈﺎﺗﻚ إﻟﻰ: ﻣﻜﺘﺐ اﻟﻤﺴﺠﻞ ﻋﻠﻲ اﻟﻌﻨﻮان اﻟﺘﺎﻟﻲ : : Registrar’s Office, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 (telephone number 9380-3703). ان ﻣﻦ ﺣﻖ آﻞ ﻣﺸﺎرك اﺳﺘﻼم ﻧﺴﺨﺔ ﻣﻦ هﺬﻩ اﻟﻤﻌﻠﻮﻣﺎت
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Appendix 4: Interviewing Guidelines
Background Information:
Questions about age, housing, financial status, social status, education, level of religiosity, children, the relationship between the parents and relatives, economic situation, job type, whether employed or not employed.
Familial relationship
Questions about familial support, the main support providers, and family opinions about the mental health problems; their general relationship with parents and other relatives.
Diagnostic information:
Diagnosis by the psychiatrist, causes of mental health problem, medication, onset of problem, length of problem, descriptions of symptoms, treatment approaches, difficulties related to mental health problems, expectation of the future of the mental health problems.
Coping with the problem
Questions related to mental health professionals: opinions about psychiatrist’s approaches and diagnosis; level of satisfaction with Clinic services; alternative coping approaches, and opinions about these approaches.
301