Treating Muslim clients with depression

The Therapeutic Relationship

BA therapists display a genuine concern and compassion for their clients. The therapist should accurately reflect what the client is saying, and the therapist should continuously reflect that the details of the client’s life and how the client feels make sense and are understandable. The therapist should always maintain hope and optimism about change.

Characteristics of Good BA Therapy

[Production note: in the source version, this section is a matching exercise sorting statements into “good therapy” vs. “ineffective therapy.” “Good therapy” includes: the therapist recognising that he or she is not always right; being collaborative and open to the client’s influence. “Ineffective therapy” is marked, among other things, by the therapist and client working on the problem individually instead of collaboratively.]

1. Activation assignments should be determined collaboratively, using feedback from the client on what the client feels would be a graded improvement.
2. Consider what the client feels his or her environment will respond positively to, and what the client feels will be an accomplishment.
3. The therapist should not guarantee the outcome of an activation assignment.
4. Activation assignments should be presented as experiments, things to try, and the outcomes should be discussed and decided on collaboratively.

Therapists may also be uncomfortable with the religious material in the manual because they are not experts in, or knowledgeable about, Islam. This could be handled by the therapist being completely honest about his or her training and expertise and saying something like:

“I have had training to deliver the therapy I will be using with you and have learned about some Islamic teachings as part of this training. I am not a Muslim/expert in Islam, but the people who have developed this treatment have worked with experts and developed some approaches that I hope will be helpful to you. This treatment is about you, your beliefs and what is important to you, so I have tried to develop my own knowledge in order to be as helpful to you as possible.”

A discussion about how the client feels about the therapist’s religious background, that does not exaggerate or try to minimise differences, will be helpful (Gorkin, 1986).

There is evidence that Muslims can be disempowered by healthcare practitioners who do not respect their religious identity (Mir and Sheikh, 2010). Our research showed that adapted BA for Muslims had a transformative effect on therapy for clients and therapy services. Clients who had previously had therapy felt more understood and were able to engage at a deeper level than in previous treatment. This resulted in significantly better outcomes from therapy compared to clients who received standard treatment (Mir et al., 2023).

Finally, there may be some therapists who – perhaps because of their own beliefs or previous training – are so uncomfortable that they are not prepared to work with a client who wishes to draw on his or her religious framework in the way promoted by this manual. Client preference is an important consideration for decisions about whether to incorporate religious components into therapy (Hook et al., 2009; Worthington, 2001) so in this case we suggest the therapist should support the client to be seen by someone who can deliver the intervention we have developed.

Time to Reflect…

Do you agree or disagree with the following statements?

• If religion is important to people they will raise it themselves.
• It is appropriate for therapists to ask clients about their religious beliefs and practice if religion is important to the client.
• Religion can help the client take a more positive outlook on life and on their problems.
• Muslims often believe that depression is the result of weakness in faith and someone who has depression must be a poor Muslim.
• I don’t think it’s professional to acknowledge my religious beliefs in a work environment.

[Production note: this reflective exercise has no single “correct” answer — it is designed to prompt therapist self-awareness.]

Discussing Religion

Initial sessions should include assessment of values and goals, including religious values (see Appendix 2). Discussion of homework activity can also be used to explore the significance of religion to clients (see Session 2 outline).

Our key informants pointed out that religion is not a central aspect of identity for every Muslim person and there is evidence that for some its influence can be similar to that of family and friends (Mir and Sheikh, 2010). However, because Islam is likely to have formed part of the upbringing of most Muslims, a client’s relationship with God is likely to feature in some way for the majority of people, including when they are struggling to make sense of their identity. Our research showed that people did not feel under pressure to incorporate religion when offered this therapy. Many individuals who were not overtly religious did consider Islam to be important and were familiar with Islamic concepts that are relevant to therapy. The express prohibition of suicide in Islam, for example, can act as a powerful deterrent when clients can see no other reason to go on living. Service users told us that when they felt extremely depressed, their faith could be the last thing to which they held on and the only thing to which they were able to respond.

It should also not be assumed that clients who usually draw on religion positively will always do this – our pilot showed that sometimes such clients could focus on negative feelings such as sinfulness or guilt, that could increase or maintain depression. Therapists should ask whether clients sometimes have such feelings and encourage them to find out about religious teachings that help them frame their experience more positively. Many such teachings are contained in the Client Booklet described in the next section and this could be a helpful resource for such clients.

Clients should be specifically asked how/how much they would like to include attention to religion in their therapy. It should not be assumed that clients with strong religious values, for example, will feel that religious activity is relevant to their therapy, particularly if they are already active in practicing their religion. Similarly clients for whom religion is not a central value may nevertheless appreciate assignments that help them increase their practice of Islam.

Where religious advice/knowledge is very important to the client, the therapist should discuss involving someone with in-depth knowledge of Islam. This can be important in motivating clients who want to practice Islam more but are finding this difficult. The client may already know someone he or she could approach but therapists should also try to build up their own professional contacts to ensure the quality of advice given is high (see Community Resources below).

Suggestions for Discussing Religion in Therapy

• “This treatment is about you and what is important to you and you have mentioned that spirituality is an important value for you. How would you like us to pay attention to spiritual activity during therapy? How much would you like this to be a focus of your therapy?” — Therapist
• “I am not an expert in Islam but I have had some training to develop my knowledge about the links between Islamic teachings and this therapy in order to be as helpful to you as possible. How do you feel about my supporting you to use your religious beliefs during therapy?” — Family Therapist
• “Do you ever feel guilty or sinful or angry because of your religious beliefs? Do you know of any Islamic teachings that might help you think about your experience in a way that is more helpful to you? How could you find out more about positive Islamic teachings?” — Clinical Psychologist
• “Do you think it would be helpful to involve someone with in-depth knowledge of Islamic teachings to advise you or motivate you to achieve the goals you have identified?” — Clinical Psychologist

The Client Booklet

A booklet bringing together various Islamic teachings that may help clients use ‘positive religious coping’ (Pargament, 2001; Koenig et al., 2001) accompanies this package. The booklet was developed as a result of feedback from other research on mental health in Muslim communities (Maan, 2010) as well as advice from our project management and service user advisory groups.

Many clients involved in our research and our Service User Advisory Group appreciated the integration of religious activities and teachings into the treatment and wanted to see a clear link between the therapy and the Islamic teachings in the booklet. Others felt they already knew what was in the booklet and did not read it much but were nevertheless positive about it. Some therapists also felt positive about using the client’s value framework to promote what the therapy is trying to achieve, whilst others felt unsure about how to use it.

It is important to remember that the booklet is intended to be a resource for clients who wish to draw on their faith as a support as well as a means for therapists to increase their knowledge of Islamic teachings that clients may find helpful. Therapists are not required to believe in the teachings themselves but should be familiar with the content of the booklet. It is very important to assess the client's degree of religiosity and not make assumptions about whether he or she would find the booklet helpful; it should not be offered immediately to clients, or before therapy has even begun, but can be suggested to those who have referred positively to religion in relation to their values, beliefs or activities. The booklet does not rule out more open discussions about what Islam might teach on specific issues that are important to the client.

The suggestions below are designed to support therapists to introduce and discuss the booklet with clients who have clearly indicated they wish to draw on their religious beliefs during therapy:

• “The people who developed this therapy have produced a self-help booklet for clients which contains Islamic teachings that you might find helpful. I wondered if you would be interested in looking at this for your homework this week?”
• “How helpful do you think the self-help book is? Were there any parts of it that you thought could support the goals you want to achieve?”
• “How would you feel about my supporting you to work through the booklet when we meet and think about how it could help you become more active?”
• “Would it be helpful to involve someone with in-depth religious knowledge to support you to work through the booklet?”

The booklet should be used to draw parallels between BA and Islamic teachings, placing the therapy within a framework that the client values and is already likely to understand. As such it enhances BA approaches, rather than acting as a substitute for these. (The source version includes a table showing how teachings in the booklet relate to the underlying concepts of BA and the idea of ‘positive religious coping’.)

An audio version of the client booklet is available for those who would prefer to listen to the booklet, via the University of Leeds Clinical Psychology website.

The Client Booklet can be found in the appendices. It contains space for clients to add their own quotations and any teachings they have found especially helpful. The techniques and tools of BA may be specifically used to help clients integrate the teachings they find most helpful with the treatment for depression. For example, the five or ten teachings clients think are most important can become “activation” assignments and the therapist can work with the client to get him or her active in these ways.