Religious activities and family/community involvement

Scheduling Religious Activities

Religious behaviours should be treated like any other behaviour to be activated in BA and the therapist should think about issues of shaping, scheduling and structuring the behaviour. Think about how religion can be drawn on as a resource within or outside therapy sessions. Here are some examples taken from our fieldwork, Advisory Groups and existing studies.

• Religious practices, such as performing daily prayers, reciting the Quran, and being prayed for by others, were confirmed as particularly effective responses to depression (Cinnirella and Loewenthal, 1999). Members of our Service Users Advisory Group reported that passing time can be a big issue – reading the Quran, praying and dhikr (remembrance of God) keeps people occupied and helps them feel less alone. Talking to Allah or writing a diary addressed to Allah can help clients make sense of things when feeling overwhelmed.
• The Client Booklet aims to support both therapists and clients to increase their understanding of key concepts in the Quran that can help clients use positive religious coping (Pargament, 2001; Koenig et al., 2001). For example, illness is described as a test in the Quran and depression can also be seen as a test that will not endure (Youssef and Deane, 2006). Clients could be encouraged to read the booklet and identify any teachings that they find helpful. The booklet also includes space for clients to add their own notes or thoughts about these or other teachings.
• Stories of the prophets mentioned in the Quran can provide a rich source of material for developing resilience in the face of difficulties or to help clients work through specific problems, for example problems with family relationships. Muslim clients can find the personal example of the Prophet Muhammad (the Sunnah) particularly helpful as there are so many Prophetic traditions (Hadith) that cover an enormous range of issues and situations.

“…if you look at the example of the Prophet himself, people learned tremendous amounts from him, from his way of being, because he was so balanced. So…you know it's like if I'm somebody who is really scared of relationships and I see somebody who is very good at relationships, I can learn a lot just from being in their presence.” — Family Therapist

• Where an inaccurate understanding of religious teachings is contributing to depression, some education about the correct understanding can be included in BA if the therapist has the religious authority to provide this. However, where the client does not accept the religious authority of the therapist, it will be unhelpful to enter into debates about a client’s interpretations of religious teachings (Peteet, 2009). The therapist can, however, encourage the client to seek out alternative interpretations from those they consider to have religious authority as an activation assignment, and involve religious teachers if standard BA techniques do not help (see Community Resources).
• Clients might not feel able to raise issues relating to supernatural causes of depression themselves in case they are misunderstood or dismissed. Initial assessment should include a detailed discussion about what the person sees as the cause of the depression. If supernatural causes are mentioned the therapist should demonstrate sympathetic understanding and encourage discussion about what responses to such situations are encouraged by Islamic teachings (see Discussing Depression). The manual should be seen as part of a package of care if necessary and collaborations with others who can help the client should be explored.
• Assessment should include a discussion about spiritual values that is fairly open-ended, but which can become much more detailed and specific if these are identified as important (see Appendix 2). The level of congruence between the client’s daily activities and his or her religious beliefs should be explored in Session 2 and, where the client feels there is a mismatch, activities that would help improve congruence should be discussed. Small steps to increasing religious activity leading from one activity to another should be encouraged rather than large and unrealistic goals.
• Literacy and childcare responsibilities that make it difficult to complete homework activities are a cross-cultural issue and will need reviewing on an individual basis (see section on General Issues when Conducting BA).
• Activation assignments may target poverty, unemployment, social exclusion issues (eg discrimination, negative media coverage) and poor health if the client feels ready to address these. BA may be framed as empowering the client to fight these battles and not give up. Therapist support and modeling of helpful behavior for issues that may cause or exacerbate depression is very useful to clients; for example in our pilot study one therapist rang up a school and housing department on behalf of a client to explain about the difficulties she was facing and reduce the pressure they were putting on the client. Deciding how to behave in the face of social adversities and listing some of the behaviours that could be helpful, including those encouraged by Islam for clients who would find this helpful, could help with experimenting these encouraged behaviours and increase resilience. At the same time it should be recognised that clients may have limited ability to influence the social context in which they live and this context may continue to cause and maintain depression.

“…one of the skills of a BA therapist is… actually coaching the change, because the main agent of change is activity scheduling so… In terms of stigma, again I think it's down to functional analysis with the individual about how they might approach and deal with those things… What we can't do of course is get rid of that sort of stigma in whatever community because it's there. It's thinking about the impact that either the real stigma or the fear of stigma is having on that person's engagement in their world and then discussing that with them.” — BA Practitioner

Graphic representations that help clients express themselves using pictures have been found helpful for those who find it difficult to articulate their situation or emotions verbally (Alyamy, 1995). Whilst Islamic teachings discourage the representation of human forms, not everyone will observe this teaching. The therapeutic value and need for treatment may be used to argue for flexibility on this issue for those with reservations (ibid). The choice about how far religious boundaries need to be maintained should, however, be made by the client rather than the therapist (Gesundheit, 2008).

Family and Community Involvement

Involving Family Members

In general, the evidence both from existing studies (Al-Issa, 2000) and our fieldwork suggests that involving family and social support early in treatment can be important for some Muslim clients. Muslim clients may fear stigma within the family or extended family if they disclose that they are being treated for depression — Pakistani key informants reported that derogatory terms such as ‘pagal’ (mad) or ‘challa’ (simpleton) could sometimes be used for people with depression (see also Dein, 2008, for similar dynamics in Bangladeshi groups).

Religious teachings cover the rights and responsibilities of family members such as parents, children, husbands and wives. Individuals may feel unwilling to challenge those to whom they have a religious duty of respect as this could result in crossing religious boundaries. Therapists may need to support clients to develop assertiveness skills that maintain respectfulness and do not cross these boundaries. Naeem (2010) suggests a tactic of apologetic assertiveness, where the duty of respect is acknowledged as a precursor to further discussion.

“…which I call ‘apology technique’, so people… before they disagree, they say ‘I'm really sorry, I apologise… but I have this point of view which is slightly different from yours... but I still respect…’” — Farooq Naeem, Psychiatrist

[Production note: this section includes several “select the TRUE statements” quiz interactions in the source version. Key points, all confirmed true in the source answer key, are summarised below:]

• Most therapists feel that families are an underused resource and engagement with family members could be important for some clients.
• Building a relationship with family members could be particularly important where the client’s access to therapy requires support from other family members — one key informant described a client who was depressed because of a physical health problem that had not been treated; persuading her husband to take her health more seriously increased her access to help for both conditions (Al-Krenawi et al., 1994, highlights the importance of engaging with family power structures in such situations).
• The therapist, as a neutral party, may be able to raise issues the client feels unable to because of perceived boundaries between family members; the therapist should also empower clients to discuss difficult issues with family members themselves, and where a family member has been asked to attend sessions but has refused, the therapist should help raise the relative’s awareness of why this could be helpful and try to persuade them to attend.

Family expectations can keep people active when otherwise they might not continue with certain behaviours. For example, a service user continued attending the congregational Friday prayer with his father and brothers even though he had stopped praying in private because of his depression.

The rights of some family members may be promoted more than others within families and communities, distorting the balance in these relationships. Valiante (2003) highlights the common mismatch between Islamic teachings and actual family dynamics in Muslim communities. Dominant family members (e.g. parents, husbands and in-laws) may use their understanding of Islamic teachings to apply pressure and produce guilt in other members. Drawing on religious teachings about rights and responsibilities can help clients and family members reframe their understanding of how these relationships should be maintained. One therapist, for example, gave an example of how he asked a husband to research Islamic teachings about the rights and responsibilities of husbands and wives and how this knowledge made the client alter his views about his own behaviour.

“…We hear in the mosque of the parents' rights over the children, you never hear the rights of the children. I understand that there are rights but it is a two way process.” — Service User

Individuals may have difficulty considering their own needs before the needs of other family members. Points confirmed in the source’s reflective exercise include:

• Women with caring responsibilities may find it difficult to complete homework tasks.
• Eldest sons may feel pressure to take responsibility for younger siblings as well as parents, and be constantly in demand, even when parents or siblings do not live in the same home.
• Therapists may find it helpful to involve supportive family members as ‘co-therapists’ who can help the client make time for themselves and support them through the therapy.
• Family members can be a source of encouragement and support and may be more successful than the therapist on his or her own in getting the client to do what is needed.
• Family members can create restrictive conditions that prevent people from developing or sustaining friendships and cause them to become isolated, a major cause of depression.
• Restricted access to work and education for women HAS been shown to significantly affect levels of depression.
• Family members who have a good relationship with the client as well as with dominant family members may be able to act as mediators/intermediaries in situations where family members are restricted in some way.
• Religious teachings about individuals’ rights can increase the confidence of clients to challenge injustices they feel are contributing to their depression.

Where a therapist feels that family relationships are abusive to the extent of breaking the law, for example where violence or abuse of children is involved, the normal process for dealing with such situations should be followed.

If the relationship is more complicated and not clearly supportive, the therapist should tell the client that they will need to work out how to get the family member to be helpful, and it may be an important aspect of treatment.

If it is unclear whether the family member can be helpful in session, it is not suggested that the therapist encourage family involvement early in treatment. Instead it is best to spend some additional time with the client determining how and if the person can be supportive. For example, it obviously is important to work with the client to address the difficulties that may be arising in the home if a spouse is not supportive. If the spouse does not have time because of a busy work schedule, it is important to discuss with the client that it would help facilitate treatment if they could find a time when the spouse could come into session. This may include having sessions in the evening or on weekends if possible or having the spouse come for a short period of time (Kanter, 2010).

Community Resources

Our fieldwork confirmed that partnering with faith-based and community organisations can support the development of cultural sensitivity in health interventions (Bopp et al., 2009). Key informants felt that therapists who had links within Muslim communities could draw on these as a resource for individual clients and also to raise awareness of mental health issues in ways that would improve wellbeing at the community level.

Alongside medical, or allopathic treatment and therapy, Muslim clients may also seek help from a range of alternative practitioners, such as spiritual healers, herbalists (hakims) and homeopaths (Sembhi and Dein, 1998; Shaikh and Hatcher, 2005). The context in some of the countries from which Muslims may originate is that trained mental health professionals are rare and greatly outnumbered by traditional healers, who may consequently be the first choice for treatment (Shibre et al., 2008; Shaikh and Hatcher, 2005), particularly for older people who have been brought up with this tradition. Furthermore satisfaction with such healers may be higher than with practitioners in health centres (Shibre et al., 2008).

“…The two go together very commonly, that people go and see a doctor, but concurrently will see a healer and an Imam and sometimes several healers…” — Therapist

Existing studies show that alternative treatment is likely to be sought by people from Muslim communities for reasons relating to faith beliefs and accessibility as well as the perceived ineffectiveness and social stigma attached to allopathic treatment (Sembhi and Dein, 1998). Amulets and visits to the graves of pious people are not promoted in Islamic scriptural sources but may be perceived as faith-based solutions to depression and our key informants accepted these practices as part of the client’s belief system and did not undermine these. Family pressure and positive community opinions may also play a role in promoting these practices (Shaikh and Hatcher, 2005).

Studies of South Asian service users in the UK have revealed concerns about communication and attention to religious needs and a need to improve mental-health services (Bowl, 2007). Muslim minorities elsewhere have also expressed concerns about confidentiality and lack of trust in service providers (Youssef and Deane, 2006) and all these issues were raised by some of our own key informants.

“…their worries are around the therapist, are around confidentiality… They might tell my parents. They might tell my husband, that type of thing... my wife…” — Mental Health Services Manager

Lessons can be learned from community practitioners in relation to these issues (Shaikh and Hatcher, 2005) and culturally integrated services have resulted from innovative approaches that build on traditional pathways for treating mental health and bring together the diverse models of healthcare (Mubbashar, 2000). Key informants did also, however, highlight a risk that the distress of people with depression could be exploited through some alternative practitioners. There were reports of people being charged large sums of money for alternative treatment (see also Dein, 2008) and some key informants suggested that those who did not charge for their services were likely to be more credible and work in the interests of the individual.

Companion Video Transcript

In line with the culturally adapted version of behavioral activation on which this manual is based, it is recommended to consult with the client about family involvement during the first session of therapy. However, some therapists suggested that family members could be involved before sessions start in order to obtain support and enhance their understanding of how therapy might help the client. In all cases, it is important that the client decides whether or not family members should be involved and that he or she is able to discuss this without family members being present. The therapist should discuss family involvement more than once with clients. Our research showed that some clients did not realize or remember that this option was possible and felt it would have been valuable.

The adapted approach to behavioral activation developed by Kanter in 2010 contains specific suggestions for how to discuss family involvement in treatment with the client and these were confirmed by our own evidence as likely to be helpful for Muslim clients. First, the therapist should tell the client that it is up to him or her how much their family can be involved. But the therapist would like the family to be involved to help the client with the primary goal of treatment, taking action. Family members can be useful in reminding clients about activation assignments and encouraging completion of assignments. Thus, ideally, family members are fully informed about the treatment plan and the functional conceptualization of depression as presented in behavioral activation. Often family members will appreciate meeting with the therapist to learn about the diagnosis of depression, what it means, and the treatment plan.

In addition, often family members inadvertently reinforce avoidance, passivity, and other depressed behaviors by taking responsibility from the client, offering sympathy for sick role behaviors, and so forth. While behavioral activation does not suggest that family members should be cold or uncaring toward the client, the family should be focused on responding to the client in ways that will be helpful in the long run. This may involve contracts between family members, that the client will be lovingly encouraged to continue household responsibilities, get out of bed and so forth, and that family members will not do the client's dishes, laundry, etc. If so doing, it will reinforce depressed and passive behaviors.

The therapist should tell the client that family members can be invited to the session and ask the client how he or she feels about inviting family members in to session. If the client is interested in bringing a family member in to treatment, the therapist needs to develop an understanding of the nature of the relationship with the family member. If the person is clearly supportive and helpful, arrangements should be made to bring the person to session as soon as possible and involve the person as much as possible. Ideally, the family member should come to the second session.

If a husband is being invited to treatment, the therapist should get the client's permission and call the husband him or herself rather than relying on the client. The therapist should really try to sell the treatment to the husband, convincing the husband to come. Would you be willing to come to our session next week? It would be so important for you to come to a session…