Discussing depression

Discussing Depression

[Production note: original video not yet ported; transcript of the narration below.]

Muslim clients will vary considerably with respect to knowledge about depression and familiarity with psychiatric terms such as symptoms and diagnosis. In BAM, it is not important that the therapist educate the client about depression or the symptoms of depression. The BAM therapist does not have to use the word depression while working with clients. Instead, the therapist should learn the client's language and descriptors of their problems and fit the behavioral activation model to the client's language. The therapist should provide a good rationale for treatment that links the treatment techniques to whatever problems the client presents with.

For example, explanations for depression amongst people from non-European backgrounds may be expressed somatically or linked to environmental causes. And this holistic understanding of body, mind, and social environment will need to be taken into account during diagnosis, assessment, and therapy. Generalized bodily pain and physical symptoms are strongly associated with depression in many studies of Muslim populations from diverse ethnic groups, and clients may deny being depressed. This is not a problem and the client does not need to be convinced to talk in emotional terms. Treatment doesn't need to shift in this way. The therapist should use the client's language and terminology for how they are describing their experience and use the somatic symptoms directly in the model. Usually these somatic symptoms can be seen as common responses and the therapist will want to focus on activating the client to maintain healthy lifestyles in the presence of these symptoms.

A physical expression of depression may not apply to all individuals within Muslim populations. However, we found evidence both within our fieldwork and existing studies that terms such as depression and stress are used by Muslims in the UK as well as in other countries as a result of exposure to such terminology and to western models for understanding depression. Service users also highlighted the stigma that could be attached to depression, which could be perceived as being mad or failing to draw on Islamic teachings or turn to God as an appropriate response to sadness or distress. This perception may be a factor in Muslim clients' reluctance to admit to depression.

Such perceptions are not inevitable, however, and in the UK context, a study of predominantly Muslim South Asian inpatients found little evidence of excessive stigma associated with receiving mental health treatment. Our fieldwork also confirmed that depression may be linked by some Muslims to Islamic teachings about the existence of supernatural forces and the existence of magic or evil eye. Belief in possession or the influence of jinn — supernatural beings which may be either good or evil — as a reason for mental illness is accepted as possible in rare situations by Muslim scholars.

Key informants said that the connection between mental illness and supernatural causes is often made when clients self harm, hear voices, have unexplained pain, or have suicidal thoughts. The context in which clients may describe such experiences can also often involve family conflicts and the therapist can explore this by asking what the client thinks is the reason for supernatural forces to affect him or her. We found this both in UK Muslims and in Pakistan. Their explanations are biological, psychological, social, but also spiritual and paranormal — so rather than the biopsychosocial model alone, there are two more aspects: spiritual and paranormal.

Within Muslim societies, possession has historically been perceived both as a test of faith with the consequence of supportive treatment, or a punishment for sins, in which case individuals are considered to bear more responsibility and therefore isolated and stigmatized. Both interpretations may exist in modern Islamic societies, but Islamic teachings promote supportive practices such as encouraging people to protect themselves through recitation of the Quran and prayers, and exorcism by a knowledgeable and devout person. Where a client believes supernatural forces are involved in causing his or her depression, explain that therapy can still be helpful alongside other actions that might be needed to counter these forces. Exploring with the client the possibility of collaboration with or referral to religious leaders may also be effective in supporting people in this situation, and the client may already be taking such advice. The list of resources at the back of this manual includes organizations that can provide advice and support for this.

Shame and stigma may be reasons for not accessing professional help and lead to some Muslim clients preferring private coping strategies. These factors can be linked to cultural taboos about disclosing personal or family problems to outsiders and the potential adverse impact this may have, for example, on future marriage prospects. However, there is also evidence that the tolerance for mental illness can be very high in Muslim populations, provided the illness can be understood within a culturally acceptable framework. For example, depression resulting from a marital problem would be perceived as understandable and not stigmatized, whereas depression that is isolated from its cause and explained in biological terms, or in ways that indicate deficiency within the individual, would be associated with stigma.

The psychological model promoted by services is therefore important in terms of how the service will be perceived, and BA emphasizes that depression is an understandable response to the context in which it occurs. An emphasis upon action rather than on understanding the pathology of depression is considered to be more in line with the values of people from Muslim communities. The therapist should explain that therapy will be completely confidential and is not about working with some problem inside the person, but is about helping people solve the problems they think are important. The therapist may say, “Listen, my goal is to help you solve the problems in your life and get moving again so you feel like life is working better for you. I can help you with that. I can understand why you feel the way you do, and I would like to help…”