Introduction

In this case study I will present Amir, a client of mine (the name of my client has been changed for confidentiality purposes).

Detailed assessment shown that Amir’s symptoms fulfilled the criteria of obsessive compulsive disorder, a common anxiety disorder. The essential features of this disorder are recurrent, severe and time-consuming obsessions and/or compulsions. Amir’s obsessions are thoughts about the exactness and a need to have certain items arranged in a particular order. Amir was compelled to perform several behaviours (compulsions) during the day.

Obsessive-compulsive disorder is a frequent, chronic and debilitating neuropsychiatric disorder with an approximate lifetime prevalence of 2–3%. Modern approaches to treatment of obsessive-compulsive disorder (OCD) are characterised by their evidence-based nature and the treatment itself follows the bio-psychosocial model. In the bio-psycho-social model religion is considered to be one of the most important psycho-social factors that contribute to mental health. In this case it was imperative to recognise how Islam can modify the treatment and prevention of Amir’s mental health disorder.

Islam is considered to be a way of life rather than simply an organized religion due to its comprehensive nature. Guidance is provided for many aspects of life including the spiritual, family, social, political and economic. Since spirituality and religion are often pervasive and central in the lives of Muslims, it would be valuable to integrate this aspect into the process of psychotherapy.

Bearing in mind Amir’s social and religious background it is important that the clinician who work with Amir, at the stage of assessment and treatment, have an understanding of the Islamic faith and practices, and was able to integrate culturally appropriate techniques. Additionally,  there is a potential philosophical dissonance between Western psychotherapy and the Islamic tradition such therapeutic interventions should be undertaken with care.  However, several studies have found that religiously appropriate psychotherapy maybe effective with Muslim clients.

Assessment

The severity of OCD differs markedly from one person to another. Even though individuals may be able to hide their OCD often from their own family, the disorder may have a negative impact on social relationships and may lead to frequent family and marital discord, separation or divorce. OCD also interferes with leisure activities, and with a person’s ability to study or work. Due to the secretive nature of the disorder, there is often a delay of more than ten years before patients come to psychiatric attention. This was the case with Amir who suffered for many years before actively looking for treatment.

The process of Amir’s assessment required direct questions. However, it was likely that Amir would be reluctant to report his symptoms, particularly that these symptoms may be perceived as embarrassing.

Our initial, structured interview led to the establishing of a working diagnosis. In the next part of the assessment I made use of some standardised instruments to help me in defining the symptom profile and estimating the severity of Amir’s impairment. Amir completed a short questionnaire – the Obsessive Compulsive Inventory, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).

Symptoms/Diagnosis

Amir reported experiencing intense distress when his shoes are placed asymmetrically or when a key is not inserted into a lock “just right”. Amir’s belief is that only by repeating these behaviours can he prevent terrible things from happening. These highly ritualised acts prevent Amir from experiencing high levels of anxiety and panic attacks. Amir’s obsessions and compulsions cause marked distress and interfere significantly with his occupational functioning, social activities and family relationships. It is not clear whether Amir fully recognised that his the obsessions and compulsions were excessive and unreasonable.

There is growing recognition among researches that individuals suffering from OCD have a highly variable level of insight into their disorder. Some OCD sufferers may show stable but low levels of insight, others may show insight when not confronted with the feared situation, but lose this insight when their anxiety is high in situations associated with their obsessive fears.

Treatment

National Institute of Clinical Excellence examined the evidence base supporting the efficacy of all therapies for obsessive-compulsive disorder and in the published guideline from the National Institute for Clinical Excellence (NICE). NICE guidelines suggest that Cognitive Behavioural Therapy should be the first line treatment for mild OCD for adults (NICE , 2005). In severe cases of OCD the treatment should be combined with medications. CBT should be the first line of treatment.

Researchers found that many Muslims are hesitant to seek help from the mental health professionals in Western countries. This occurs mostly as a result of the differences in their belief system and the helping professionals’ lack of understanding about Islamic values in treatment modalities. Consequently, Muslims might feel uncomfortable in seeking psychiatric help to avoid being in conflict with their religious beliefs. However, thanks to my extensive knowledge of religious traditions I managed to create a trusting therapeutic relationship with Amir.

Psychological treatment

Behavioural therapy was the first psychotherapy for which careful empirical support was obtained, and is useful in treatment of OCD in adults and children. An important component of behavioural therapy is exposure to the feared stimuli. Exposure techniques entailed assisting Amir in generating a hierarchy of feared situations in which he then would practise facing the fear (exposure). As a result of a continuous exposure to feared stimuli Amir’s anxiety levels lessened without the need to carry out a ritual (response prevention).

Part of the traditional Islamic knowledge known as Hadeeth 32 says: There should be neither harming [darar] nor reciprocating harm [diraar].  In order not to alienate Amir, clinicians need to make a determination based on ethical boundary in respect to which “harm” is greater: the exposure or the suffering from OCD? According to the scholars of the Arabic language, ad-darar refers to the noun and ad-diraar refers to the action/verb and so the meaning of ‘no darar’ is that none of you should harm any other with something that they have not harmed you with first. And the meaning of ‘no diraar’ is that none of you should harm any other at all (http://www.bible-quran.com/islam-hadiths-hadiths-32-34-nawawi/). Subsequently criteria of what constitutes normality and the means by which normality is assessed have been set in a culture-specific context.

In terms of the cognitive aspects of cognitive behavioural therapy of psychological disorders the theory asserts that maladaptive or irrational thinking styles (thoughts, maladaptive assumptions and dysfunctional schemas) within several psychological domains lead to emotional or psychological disturbance. The  Obsessive-Compulsive Cognitions Working Group proposed the several important belief domains in OCD, such as, inflated responsibility, thought-action fusion, perfectionism, controllability of thoughts, overestimation of thread and intolerance of uncertainty. Indeed, the work within these domains has been a large part of the process of therapy with Amir.

In the process of cognitive behavioural therapy, Amir identified the following automatic thoughts, maladaptive assumptions and dysfunctional schemas:

Distorted automatic thoughts:

“I can’t stand my anxiety”, “What if I forgot to lock the door? It will be my fault if we have a burglary”, “I have to be sure”, “I’d better check. Otherwise the house could burn down”, “Better safe than sorry”, “This has to be perfect”, “I must do it right”.

Among maladaptive assumptions were:

“All risk must be avoided”, “You must be absolutely sure things are safe, otherwise you’re in danger”, “I am to blame if I don’t take all possible precautions”, “Things must be perfect to be good enough”.

Dysfunctional schemas:

“Other people cannot be relied upon for safety”, “I am the only one I can truly count on”, “I am inherently responsible unless I try very hard”.

The clinicians may consider using spiritually modified cognitive therapy, by replacing certain concepts used in Western cognitive therapy with concepts drawn from Islamic teaching with which Amir is more familiar. From an Islamic perspective, these unwanted obsessive thoughts are called wasawis, which are whispered into the minds and hearts of people by Ash-Shaytan (Satan). We can find evidence of this in the holy Quran and Hadith.

The process of integrating religiously based concepts and beliefs in the context of a cognitive-behavioural therapy approach essentially involved replacing Amir’s damaging beliefs and attributions about himself, others, and the world with more positive religious based beliefs. A large number of studies have proved such modifications effective for clients with spiritual believes about themselves and the world around them.

In the process of therapy I used several variations of CBT, such as, Mindfulness Based CBT or Acceptance and Commitment Therapy (ACT). The philosophy of these therapeutic approaches is virtually identical to Islamic contemplation and Sufism. These psychotherapies encourage non-judgmental metacognitive awareness of thoughts and feelings as passing events rather than inherent aspects of the self or reality. The tradition and teachings of Sufism  are similar to those of MBT and ACT, and can have beneficial therapeutic outcomes. Even those scholars who do not agree with the traditional counselling for Muslim clients frequently consider Sufism as the basis of an original counselling model in Islam.

Ethical, Cultural and religious implications and recommendations for clinical practice

Many scholars have asserted that traditional forms of psychotherapy were developed within a context in which normality was characterised by belief, observations, cognitions and perspectives of middle to upper class heterosexual European and European-American men. A lack of clinical awareness at this basic level may lead to misunderstandings, premature termination and even mistaken assignments of client with respect to psychiatric disorders at every level of therapeutic contact, from initial interview to case conceptualisation, assessment and diagnosis. British Psychological Society and Health Professional Council make mention of religion as an area of diversity that should be attended to. This notion opens doors to many other crucial elements in therapy provision such as the importance of therapists’ self-awareness of own beliefs and the process of traversing the boundaries between serious mental health and pathologising strongly held religious or spiritual beliefs.

It is also important to mention the ethical concerns that have arisen in the process of implementing spirituality in the context of Amir’s treatment.  Concerns , such as, dual relationships (professional and religious), imposing religious values on clients, informed consent issues and professional competency issues. Among other potential concerns are:  violating the therapeutic contract by focusing on religious rather than therapeutic goals, applying only religious interventions to problems that may require medication or other treatments, obscuring the boundaries that are important for the therapeutic relationship to be maintained, assuming religious authority and performing these functions, when referral to religious leaders may be warranted.

In order to avoid these problems and to determine the appropriateness of spiritual integration a thorough assessment of Amir’s religious and cultural issues was required.  A proper informed consent needed to be signed and it was a very important to focus on establishing a strong therapeutic alliance with Amir. Further, it was important to remain flexible throughout the process of assessment and treatment and avoid the imposition of religious values on Amir. Ideally, the clinician should share Amir’s basic religious or spiritual belief system and always provide an appropriate rationale for using a particular spiritual intervention. This was not the case, however, and this is why the quality of the therapeutic relationship was of such importance here.

Even though some ideological points of discord may exist, CBT is likely an effective therapeutic modality for a large portion of this population of clients. Research described three guiding values for clinicians who are considering religious interventions: (a) respect for client’s autonomy and freedom, (b) sensitivity to and empathy for the client’s religious and spiritual beliefs, and (c) flexibility and responsiveness to the client’s religious and spiritual beliefs.

Summary

As a devouted Muslim, Amir applied his religious rules to all spheres of his life. In order to reach positive outcomes in Amir’s assessment and therapy it was essential for the therapist to understand of the Islamic faith and practices, and also to integrate culturally appropriate and effective techniques.

Cognitive-behavioural therapy is an effective form of psychotherapy for a variety of psychological conditions, including anxiety and stress, depression, eating disorders, panic disorder, and phobias. It is also one of the most evidence-based and empirically supported.

Even though the research base for the effectiveness of religiously modified cognitive behavioural therapy is limited, the cognitive-behavioural approach should be judiciously applied when treating clients like Amir. Increased knowledge about the Islamic faith and its traditions is likely to enhance the use of culturally appropriate assessment and treatment methods.