Spiritual understandings

Time to Reflect…

Thinking about how your own beliefs and values may be similar or different to your client can help you understand the impact these could have on your relationship with each other. How can you maintain a good rapport and professional boundaries in either case?

Recognise that religion is not seen as a completely private matter in every culture – Islamic teachings influence daily life for many Muslims including routine daily activities, social relationships and how people express themselves in conversation.

Support to develop links with Muslim community organisations and religious experts is best done at an organisational level so that all therapists within a service can access these if necessary. Being able to signpost clients to these places can be important if relevant to their activation goals.

Consider these questions:

1. I am aware of my own beliefs about religion.
2. Religion is important to me.
3. I respect that religion may be important to others even though it is not important to me.
4. I feel confident about engaging in therapy with someone from a Muslim background.
5. My beliefs are private.
6. I feel I am judged because I am/am not religious.
7. I know how to access information and advice about Islamic teaching if I need to.
8. I would be open to collaborating with religious experts to support a client.

Religious Background of the Therapist

Therapy can involve complex dynamics and when therapists and clients have a shared understanding of their faith their reactions to each other may inform the development of their relationship with God (Peteet, 2009). In intercultural therapy, however, establishing trust and empathy may be more difficult. Gorkin (1986) highlights conflict-based reactions in both clients and therapists that draw on the prejudices and stereotypes each holds of the other. For therapists working with Muslim patients this can result in a perception that individuals from this faith group are not psychologically-minded enough to benefit from therapy or that their beliefs and practices are from an inferior culture. Alternatively, a wish to use sessions to learn about the client’s culture (rather than focus on the client’s needs) or premature discussions of difference before a rapport has been developed, can similarly interfere with the process of establishing a helpful therapeutic relationship (Gorkin, 1986).

Some level of religious and cultural knowledge was seen as necessary by our key informants to facilitate helpful engagement. For example, awareness of common stereotypes and how religion may shape individuals’ lives and beliefs, as well as familiarity with cultural metaphors that people may use to express themselves, was important for developing a shared understanding. Therapists from non-Muslim backgrounds should explicitly express an openness and desire to talk about such issues with clients.

“I think it helps if they know a little bit about the religion or at least be curious about the religion and ultimately it’s kind of a little like an attitude thing. When I work with anyone from any kind of culture I believe that ultimately within their own cultural system there will be ways of dealing with those difficulties.” — Family Therapist

Knowledge of Islam can also sensitise therapists to issues that might cause difficulties or discomfort for clients, for example:

• Consider timing — e.g., avoid appointments that clash with Friday prayers.
• Consider gender — e.g., avoid mixed gender activities.
• Evidence interest in Islam — e.g., have a copy of the Qur'an and refer to it during therapy sessions (giving a message of acceptance).

Some of our key informants used verses from the Quran, for example, to promote the idea of hope, or drew on a Hadith about how to behave when angry to promote understanding of the link between emotions and behaviour. Ahmed et al. (2007) found that Muslim service users in Pakistan valued being treated by health professionals who expressed religious sentiments and an inclination towards God. Some of our key informants from Muslim backgrounds felt that once they had developed a relationship of trust with a client such expressions could also be appropriate in the UK context.

Our research showed that clients did not feel it was offensive for either Muslim or non-Muslim therapists to suggest religious activities as long as the therapist genuinely felt this would be helpful. However, a sensitive balance is needed between encouragement for valued religious activity and making the client feel guilty for not being active in this way already.

Whilst training about Islamic teachings is seen as necessary and useful, key informants warned about the risk of presenting Muslim communities as homogenous. They emphasised an awareness of diversity and the fact that training could not cover everything. It was felt that therapists should have undergone a process of self reflection about their own culture, beliefs and biases, both to give them confidence about exploring these issues with clients and become aware of their own preconceived ideas. Training could also provide an opportunity to share expertise and experience and show organisational support for addressing the specific needs of Muslim communities.

“They need to have explored their own relationship to faith because otherwise if they haven’t they can’t help someone else do that.” — Family Therapist

Spiritual Understandings of Depression in Islam/Muslim Communities

Our fieldwork and Service Users Advisory Group confirmed evidence from existing studies that the overwhelming majority of Muslim people with depression equate an “Islamic way of life” with good health and believe that following Islamic teachings supports healing (Ahmed et al., 2007; Coker, 2005; Shoeb et al., 2007; Tehran et al., 2009). Our key informants highlighted that not acting on one’s beliefs can contribute to depression through guilt and self-criticism. Supporting the development of congruence between beliefs and actions is promoted both by BA practitioners (Kanter et al., 2010; Veale, 2008) and by Islamic scriptures (e.g. Quran 2:177; 3:114).

“Initially it was ‘How could I call myself a Muslim if I am not praying?’ because there is… obviously the difference between a Muslim and a non-Muslim is the prayer and so… but it was how I felt after I had prayed because I felt good I wanted to do it again. … it was the lack of the anxiety and I thought ‘Well I am happy with this’ and I think it was the incentive for me to want to do it again and carry it on.” — Service User

Islamic teachings about dealing with stress promote reliance on God's mercy and support as well as acts of worship, without which the human need for spirituality is seen as unfulfilled (Esfahani, 1995). Religious beliefs and practices are therefore perceived as a resource for improving health and key informants suggested a range of religious teachings that could be drawn on during therapy for clients who would find this helpful, for example:

1. Teachings that illness and loss are a test, that God rewards patience and perseverance and can provide relief from difficulties or distress and a cure for illness (Mubasshar, 2000).
2. Stories of different prophets in the Quran can promote hope and encourage recovery as they involve persevering through difficulties and relying on God’s help to resolve these.
3. Recitation of the Quran and prayer in particular were described by key informants as important ways in which clients could feel relief from depression and hope for the future.
4. Connecting to God enabled people to make sense of their experiences, gain resilience and a sense of calm as well as the ability to prevent themselves from constantly thinking about events.
5. Rather than focusing on the actions of others, which can often contribute to depression, clients can be encouraged to think about what they themselves can do to feel better and improve their situation.

Many of these teachings are contained in the Client Booklet that accompanies this manual and others can be accessed through the resource list at the back of this resource.

Scheduling Activation Assignments

The key to BA is identifying, assigning and reviewing activities. Every session essentially involves reviewing the previous week’s assigned activities and assigning new activities. This should be approached in a way the client finds helpful, for example, some clients may prefer that the therapist suggests practical activities that seem in line with their values, rather than to be asked a very open question about what they would like to do. Other clients may prefer to explore their own priorities in a more open way or alongside advice from the therapist. Activities are assigned in detail, with the client and the therapist reviewing what, when, where and with whom activities will be completed. Obstacles to completing activities are also discussed and clients may be asked to visualize or role-play an activity. Therapists should ensure that organised activities to which the client is referred do not clash with therapy times.

Time to Reflect

Some clients may find it very difficult to motivate themselves to become active and express hopelessness about being unable to get out of bed. How can you discuss this and help them get started?

Metaphor: therapists can use the metaphor of when the battery of a car has ‘died’ we need to give it a push start before it will get moving again. The initial stage of pushing is the hardest part – once it has started it is easier to keep it going. Acknowledge that taking the first step is the hardest part but encourage clients to try so that motivation increases.

Tricks and tips: let the client know that you've been trained to help people to do this and that will help the individual get started; making the point that you will start off small and build on achievements and you will start at a level that feels right for the client.

Being so focused on concrete activities as the central theme of the session may be new to many therapists, but it is the primary emphasis in BA. For therapists who are CBT trained or used to focusing on cognition, the next section gives some ideas about how BA fits with a cognitive model and also about how to deal with thoughts in BA.

Companion Video Transcript

Whilst some Muslim clients may request a therapist of the same faith and or gender, others specifically ask for a therapist from a different background. Some clients involved in our research felt that therapists from a similar background were more likely to understand clients' cultural references and metaphors and explain the religious elements of this therapy. Clients may also feel relieved they do not have to explain or justify their beliefs, particularly when the experience of depression is affecting their ability to express themselves.

However, this common understanding should not lead to therapists crossing professional boundaries or giving advice on areas in which they lack expertise. For example, one service user complained that his GP advised him to get married as a solution to depression and felt he was being treated less professionally because of their shared background.

Clients may prefer a therapist from a different religious background if they have concerns about confidentiality or have had previous unhelpful experiences with professionals from their own faith community. Concerns about confidentiality can relate to not wishing to disclose their experience to someone from a Muslim background or worrying that someone from their community will find out about their mental health problems. Clients who are ambivalent about religion or feel embarrassed to disclose a lack of religious observance may also prefer a therapist who is not from the same faith background. Such embarrassment may also prevent disclosure to family members and friends and clients can feel more able to discuss these issues with someone outside their religious community.

Trust, empathy, and compassion as well as openness to understanding religious beliefs were felt to be the most important issues for clients with therapists from any background. Professionalism is highly valued and clients understandably do not wish to feel they are being judged by therapists of any background who are supposed to be helping them.

Ideally, a choice of Muslim or non-Muslim therapists should be offered for this intervention, but this is often not possible. There are advantages and disadvantages of having a shared and non-shared background and clients involved in our research often felt that any concerns about difference including the age of the therapist were overcome through the positive…