Muslim psychologists and psychiatrists recently published an eye-opening book titled Applying Islamic Principles to Clinical Mental Health Care. I had learned about Dr. Rania Awaad and her work in mental health at a talk hosted by Salaam Islamic Center. She is a Clinical Associate Professor of Psychiatry at the Stanford University School of Medicine and the Director of the Muslim Mental Health Lab. Discussing how traditional Islamic texts meet with the modern disciplines of psychology and psychiatry, Dr. Awaad uses the “biopsychosocial” approach; she claims that psychology, mental health, spirituality, and religion cannot be separated. As someone who shares the same understanding, I was deeply impressed with her and her team’s clinical treatment methods and their new book. It is a book about introducing Traditional Islamically Integrated Psychotherapy (TIIP), which is the culminating result of the Khalil Center’s research.

I attach importance to this book because I truly believe in the power of holistic approaches to healing. I am also involved in the Association for Psychological and Spiritual Sciences (APSS), which is similar to the Khalil Center because it also encourages psychologists, psychiatrists, students of medicine, theologians, and researchers of human sciences to discuss and conduct studies to solve many problems of individuals and societies. Additionally, the APSS mirrors the Khalil Center due to its similar work of analyzing conceptual religious and spiritual sources of oriental history with an emphasis on Sufism. Thus, predominantly Islamic sources are discussed to develop universally applicable theories, concepts, and therapeutic strategies.

Two halves of a coin

The recently published book, Applying Islamic Principles to Clinical Mental Health Care, is built upon three profound principles. First, researchers combed through traditional and foundational Islamic texts, such as the holy Qur’an, sayings of the Prophet Muhammad (hadith), actions of the Prophet (sunnah), and other general Islamic guidelines for spiritual and material well-being. Then, this well-established and prosperous literature review was evaluated, and then combined, with modern psychology. Last but not least, practical methods were then synthesized by using traditional Islamic literature in the psychology field and current modern psychotherapy techniques.

The book delivers a detailed and lucid account of the differences between the approaches utilized by modern psychiatry and the TIIP. Contemporary psychiatry is largely based upon “The Diagnostic and Statistical Manual of Mental disorders” (DSM) and “The International Classification of Disorders,” (ICD) which are used for diagnosing mental disorders. The TIIP utilizes these texts and the vast amount of clinical research that they possess, but on the other hand it also takes the Qur’an, hadith, sunnah, and other Islamic spiritual traditions into consideration. The critical difference in between the two is that the TIIP advocates for a more holistic approach to mental health that includes a person’s spiritual well-being, while modern psychiatry does not consider a person’s spiritual pathological character in order for them to require clinical treatment. 

The TIIP’s perspective is that the concept of health and pathology cannot be adequately addressed with current clinical diagnoses. According to Islam, proper psycho-spiritual health is heavily associated with each person achieving a strong understanding of their own unique ethereal purpose, and the proper treatments for gaining and maintaining psycho-spiritual health can be achieved through training. For instance, a person that suffers from an abundance of arrogance, which negatively affects various aspects of their life, does not require modern psychiatric clinical treatment. Since arrogance is mentioned as a spiritual disease in Islamic sources, a TIIP practitioner addresses this condition with a psycho-spiritual integrative approach.

The APSS explains this concept in more detail by arguing that the human being is a vast, profound, and complicated creation that longs for a sense of eternity, permanence, understanding behind creation and life, and connection to one’s Creator. Spiritual health is seen to be equally important as one’s physical and mental health since neglecting one’s spiritual health can have adverse consequences upon many facets of a person’s life. Thus, eternal satisfaction may be gained via spiritual contentment. 

Furthermore, these techniques are not exclusive only to Muslims despite their backing in Islamic theology; they could be applied to non-religious and religious individuals alike, regardless of their belief system, since Islam aims to take a holistic look at life in a way that everyone can relate to in some form.

Our “inner senses” cannot be ignored

Humans have external senses and internal senses. External senses include sight, hearing, smell, taste, and touch, and we communicate with the external world via these senses. On the other hand, internal senses are spiritual senses and are used to communicate with the inner world. They include metaphysical concepts such as the spiritual heart (qalb), soul (ruh), and different modes of cognition (sır), (hafi), and (ahfa), and much more. They are the separate depth of the heart. Humans have a wide range of uses for internal dynamics and mechanisms, and our internal and external senses should work together like two wings on a bird. Just like how we take vitamins to strengthen our physical body, we strengthen our spiritual “body” by honing our inner senses.

All of the chapters of the book are very intriguing, and it has a compelling and inspiring effect on readers to understand and apply TIIP practices. For instance, the whole chapter about “Intellect” and its methodization in Islamic Psychotherapy is remarkable. One of the most impressive indications is that the word “intellect,” which is mentioned about 50 times in the Qur’an and across various hadiths, is referred to the link between intellect and well-being. Thus, the importance of the mind is explained through a different lens. Cognitive-behavioral therapy (CBT) looks at our thoughts, feelings, and the roles that they have when it comes to how they affect our behavior. There is a direct correlation in between our thoughts, emotional health, mental wellbeing, and then our actions. The book refers to the writings of Islamic philosopher, jurist, and mystic Abu Hamid al-Ghazali and his modality in Islamic literature. Al-Ghazali offered to implement interventions among stages by addressing faulty thoughts, negative feelings, and actions. For instance, the Islamic ablution, which is often performed once before each of the five daily prayers, is given as an example during two of the stages. Those interventions would help change the focus on faulty thought and shift the state of emotion.

While the TIIP discusses the intellect it also includes three stages of “self” (nafs); the evil commanding lower self and the animalistic impulses (nafs ammarah), self-criticizing blaming stages (nafs lawwamah), and tranquil stage (nafs mutma’innah). These stages are interpreted as the spiritual elevation of the human spirit. A TIIP practitioner aims to achieve a tranquil stage for the client. TIIP gradually works with cognitive science by identifying and challenging a person’s faulty thought and then reconstructing situations, thoughts, and feelings. 

The seven stages of thought progression

In addition to the book’s description of intellect, the APSS mentions seven stages of the mind’s metacognitive dimensions and functioning system that are important information processing steps.

The first one is “imagination” (tahayyul); in this stage, false thoughts occur. The mind starts overreacting by imagining false thoughts, such as worrying about getting sick due to Covid-19 even if a person is self-quarantined and has almost no chance of getting it. In this phase, negative thoughts and apprehension happen. Then, the “envisage” (tasawwur) stage comes. Thoughts are conceptualized and shaped in this stage. An individual could start believing, or perhaps even convince themselves, that they have contracted the virus if they are constantly being exposed to negative news surrounding it. When both the imagination and envisage phases activate then thoughts start to attack an individual’s inner world. Toxic thoughts can begin entering the brain and can wreak havoc on a person in the form of abnormal behavior, anxiety, stress, and obsessive thoughts.

The fourth stage is “comprehending” (ta’aqqul), which also assess our thoughts with the goal of more clearly understanding them. Then, the “approval” (tasdiq) stage comes, and in this stage individuals understand and confirm positive thoughts in their heart. The next stage is foresight (iz’an) which starts where individuals begin to understand themselves very well and act according to their understanding. Next is favoring (iltizam). The last stage is faith (i’tikad), which involves having sincere belief, firmness, and not hesitating to act upon what a person believes to be right. The first two stages, imagination and envisage, compose the thought process and the outcomes of this process. To change faulty thoughts, individuals need to consciously intervene upon the first and second steps by “getting rid of habits.” Directly attacking the source of these negative thoughts allows a person to begin to change their faulty thinking processes. One should start with staying abstinent from being exposed to too much unhelpful information. Habits always need to be replaced in order to fill the void that is consequently made, and it is therefore recommended to engage in otherwise beneficial activities, such as reading the holy book, praying, spending time outside, engaging with people that bring joy and positive emotions, or pursuing a subject or hobby of interest.

Applying Islamic Principles to Clinical Mental Health Care: Introducing TIIP qualifies as a bedside book that every professional working with the Muslim population should read. The book structurally clarifies and demonstrates how Traditional Islamically Integrated Psychotherapy is utilized in therapy by discussing an overview of modern psychology and the traditional Islamic bibliography. Case examples are spectacularly and elaborately explained. After reading the whole concept and its case studies, readers will find answers to their questions. Whether the readers are an emotionally focused therapist, a cognitive-behavioral therapist, a behavioral therapist, or a spiritual therapy practitioner, they will benefit from this book. The book covers all four approaches under the “Treatment of the Domains of the Human Psyche” part. Therapeutic interventions can be practically implemented.

Nooriye is a 39-year-old Iraqi female. She had a pretty normal life until a group of terrorists knocked on her door. Her two sons were killed in front of her. She was abused and tortured for days, as was her husband. Rebels eventually took her husband and left. Some neighbors helped her to bury her sons and provided her with shelter and food. She was about to kill herself when, miraculously, her husband came back 57 days later. He never told her what he went through during those 57 days. They were both in extreme pain but able to hold onto each other.

They immigrated to the U.S. a year later. Her husband found a job and is still working. They are safe now, but it has not been enough to heal them. Both still have nightmares and flashbacks. She spends all her time in her home. She stares at walls, feels numb and very fearful, and cries every day. Her speech is sparse, and she never smiles. She goes out with husband once a day but grabs his hand and won’t let him go when they are out. When faced with stress, she often passes out.

Her husband “has to be strong because she is the only thing he has,” although he also has extreme pain. He hides his tears from his wife, is unable to sleep at night, feels guilty, and misses his sons. He is afraid to make any Iraqi friends and stays away from mosques.

Obviously, providing a safe place, food, and a job is not enough to heal these people’s pain. Invisible wounds and problems are much harder to treat than visible ones.

In this article we will try to elucidate some elements of what Nooriye and thousands of other families have been exposed to all around the world.

Mass trauma

When a group of people, regardless of size, experience psychological effects after a trauma that was suffered collectively, this is called a mass trauma. Sometimes an entire society witnesses the same trauma, and this may cause a collective sentiment, often resulting in a shift in that society’s culture and mass actions.^1,2

Wars, political violence, natural disasters, exile, torture, and terrorism are examples of mass trauma. The Holocaust, the Atomic bombing of Hiroshima and Nagasaki, slavery in the United States, and the 9/11 attacks are well-known collective traumas.

Collective traumas have been shown to play a key role in group identity formation. Having the same problems, suffering from the same pain, and being under the same pressures bring individuals together. This togetherness eventually helps to build a community, a group, and sometimes a nation. Almost every nation has traumatic events in their history. Even the concept of “nation” is extensively affected by these events.

Nevertheless, despite its role in building group identity, mass trauma is still individually painful. In fact, the effects of mass trauma can be very deep and transferred through the generations. In 1966, clinicians observed that large numbers of children of Holocaust survivors were seeking treatment in psychiatric clinics in Canada. Moreover, when compared to the general population, the grandchildren of Holocaust survivors were three times more likely to seek clinical psychiatric help.³

Post-Traumatic Stress Disorder

According to the National Center for Posttraumatic Stress Disorder, the most common stress reactions in the wake of disaster may include the following:

Emotional reactions, including shock, fear, grief, anger, guilt, shame, feeling helpless, feeling numb, and sadness.

Cognitive reactions, including confusion, indecisiveness, worrying, shortened attention span, and trouble concentrating.

Physical reactions, including tension, fatigue, edginess, insomnia, bodily aches and pains, startling easily, racing heartbeat, nausea, change in appetite, and changes in other bodily desires.

Interpersonal reactions, including distrust, conflict, withdrawal, work or school problems, irritability, loss of intimacy, and feeling rejected or abandoned.⁴

Several factors present in the acute-phase recovery environment of a disaster have been found to aggravate stress reactions and therefore increase survivors’ risk of developing negative outcomes. These include:

• Lack of emotional and social support
• Presence of other stressors such as fatigue, cold, hunger, fear, uncertainty, loss, dislocation, and other psychologically stressful experiences
• Difficulties at the scene
• Lack of information about the nature and reasons for the event
• Lack of, or interference with, self-determination and self-management
• Treatment [given] in an authoritarian or impersonal manner
• Lack of follow-up support in the weeks following the exposure

Protective factors that may mitigate negative effects include:

• Social support
• Higher income and education
• Successful mastery of past disasters and traumatic events
• Limitation or reduction of exposure to any of the aggravating factors listed above
• Provision of information about expectations and availability of recovery services
• Care, concern and understanding on the part of the recovery services personnel
• Provision of regular and appropriate information concerning the emergency and reasons for action.⁵

In most cases, the symptoms of trauma eventually disappear, but unfortunately, some of the survivors of the mass trauma will eventually develop Post-Traumatic Stress Disorder (PTSD). PTSD is a mental disorder resulting from exposure to an extreme traumatic stressor.

The National Comorbidity Survey Replication (NCS-R), conducted between February 2001 and April 2003 in the U.S., estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.⁶ The lifetime prevalence of PTSD among men was found to be 3.6% and among women 9.7%. ⁷

PTSD is described in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM 5) which is published by the American Psychiatric Association, as:

Criterion A (at least one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):

• Direct exposure
• Witnessing the trauma
• Learning that a relative or close friend was exposed to a trauma
• Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

Criterion B (at least one required): The traumatic event is persistently re-experienced, in the following way(s):

• Intrusive thoughts
• Nightmares
• Flashbacks
• Emotional distress after exposure to traumatic reminders
• Physical reactivity after exposure to traumatic reminders

Criterion C (at least one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):

• Trauma-related thoughts or feelings
• Trauma-related reminders

Criterion D (at least two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

• Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect

Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

• Irritability or aggression
• Risky or destructive behavior
• Hypervigilance
• Heightened startle reaction
• Difficulty concentrating
• Difficulty sleeping

Criterion F (required): Symptoms last for more than 1 month.

Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).

Criterion H (required): Symptoms are not due to medication, substance use, or other illness.⁸

Treatment for mass trauma:

Treatment for mass trauma should be delivered at two different levels: the community level and the individual level.

1. Community level:

Dr. Frantz Omar Fanon gives the recipe for mass trauma treatment at the community level: “Mass trauma can be alleviated through cohesive and collective efforts such as recognition, remembrance, solidarity, communal therapy and massive cooperation.”

The statement above can be a topic for a separate article. Here, we would like to express the importance of the remembrance days. People comes together on remembrance days and remind the victims that they are not alone and not forgotten. This can be therapeutic for the victims and alleviate their pain.

2. Individual level

PTSD treatment includes pharmacotherapy (medical treatment) and psychotherapy. Some of the medications which have been helpful combatting depression are selective serotonin reuptake inhibitors (SSRIs), such as Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as Venlafaxine (Effexor) and Duloxetine (Cymbalta).

There are several therapy types that have been shown to be effective at treating PTSD. Trauma-focused psychotherapies are the most highly recommended psychotherapies for PTSD. In these therapy types the treatment focuses on the memory of the traumatic event or its meaning. These treatments use different techniques to help a victim process their traumatic experience. Some involve visualizing, talking, or thinking about the traumatic memory. Others focus on changing unhelpful beliefs about the trauma. Prolonged exposure therapy, Cognitive Processing Therapy, Eye-Movement Desensitization and Reprocessing, Brief Eclectic Psychotherapy, and Narrative Exposure Therapy are the some of the therapies that have been found to be helpful for PTSD patients.

Additionally, spirituality might help treat PTSD, too. A study of Bosnia-Herzegovina war veterans suggested that veterans who prayed had significantly higher levels of incorporation, self-protection, and reactive formation and significantly lower levels of regression, compensation, transferring, lack of control, and aggressiveness than their peers who did not pray. ⁹

In brief, providing shelter, food, and a safe environment are mandatory for trauma patients, but they aren’t nearly enough. Psychological traumas are very hard to treat, and treatment may take years. It has been shown that soldiers who have somebody to share their war experience/trauma with, have a lower risk for PTSD when compared with the ones who can’t talk to anybody. Victims need professional help along with community support. Trauma can be alleviated through cohesive and collective efforts and cooperation. Praying for the trauma victims, as politicians suggested for recent hurricane victims, definitely has some social impact. It has also been shown that medication/prayers decrease PTSD symptoms ¹⁰; however, showing support and empathy, listening to victims, and acts of remembrance are the other key elements of community support.

References

1. Lisa Gale Garrigues, “Slave and Slave Holders Break Free of History’s Trauma“, Yes Magazine, August 2, 2013
2. Updegraff, Silvler, Holman, “Searching for and Finding Meaning in Collective Trauma, Journal of Personal and Social Psychology, September 2008
3. Coffey, R. (1998). Unspeakable truths and happy endings. Sidran Press. ISBN1-886968-05-5
4. https://www.ptsd.va.gov/professional/pages/handouts-pdf/Reactions.pdf
5. NSW Institute of Psychiatry and Centre for Mental Health. (2000). Disaster Mental Health Response Handbook.North Sydney: NSW Health.
6. Kessler, R.C., Berglund, P., Delmer, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6): 593-602.
7. National Comorbidity Survey. (2005). NCS-R appendix tables: Table 1. Lifetime prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Table 2. Twelve-month prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Accessed at: http://www.hcp.med.harvard.edu/ncs/publications.php
8. American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC.
9. Pajević I, Sinanović O, Hasanović M. Association of Islamic Prayer with Psychological Stability in Bosnian War Veterans. J Relig Health. 2017 Dec;56(6):2317-2329. doi: 10.1007/s10943-017-0431-z.
10. Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditationand yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017 Dec; 58:115-124. doi: 10.1016/j.cpr.2017.10.004.