Working with Muslim Clients: Grief, Terminal Illness & Bereavement Psychology from an Islamic Perspective Interest Group CBT Interventions Shehzi Yusaf & Wendy Sawtell Clinical Psychologists

Program Outline  Normal Grief  Complications  Therapeutic Approaches  Cognitive Behavioural Therapy  CBT-Islamic application  Islamic Beliefs – the basics  Case Scenarios  Religious Assessment  Interventions – putting it together  Therapist Considerations

Normal Grief Cognitive Sx  Disbelief / Confusion/Memory  Preoccupation / Obsessive thoughts  Sense of presence / Hallucinations / Dreams Behavioural/ Physiological Sx  Sleep / appetite disturbance  Social withdrawal / loss of interest  Avoidance of reminders  Crying / sighing / agitation / restlessness Emotional Responses  Sadness / shock / anger / guilt / anxiety / denial / irritability / worry /

Risk Factors Hx of; psychopathology Stress related medical cond.  Unexpected or violent death.  Death of spouse / child  High dependency on deceased  Lack of social support

Complications  Post Traumatic Stress Reaction Sudden traumatic death Diagnosis of terminal illness  Complicated Grief Lack of acceptance  Major / Clinical Depression Premorbid risk factors

Therapeutic Approaches  Psychodynamic  Rogerian / Humanistic  Systems Family Therapy  Cognitive Behavioural Therapy

Cognitive Behavioural Therapy  Empirically Derived  Scientist practitioner model  Evidence based interventions / optimised outcomes  Emphasizes Ax / Outcome

CBT Model Situation Thoughts Emotions Physiology Behaviour

Cognitive Restructuring Identifying and challenging;  automatic negative thoughts,  dysfunctional attitudes,  Unrealistic expectations  Irrational beliefs / schemas Muslim scholars have long held that emotional dysfunction is a by-product of irrational negative thinking (eg. Al Ghazali 11 th Century).

What Works for Muslims Cognitive Behaviour Therapy! (Badri.M,2000)  Highly detailed Islamic belief / schematic system  Islamic teachings / practices embody potent cognitive & behavioural prescriptions: decreases physiological arousal (anxiety) and enhanced emotional functioning (mood management).  Used by early Muslim scholars: exposure, cognitive restructuring.  Cognitive restructuring is fundamentally characteristic of Islamic thinking style.

Cognitive Schemas  Muslims prescribe to religious schema above all other competing schema (eg. Political, traditional etc)  Islam is a powerful instrument for cognitive realignment  Islamic psychology uses CBT, offering key to unlock / access / modify schema for enhanced pt wellbeing / outcomes.  Issue of CONGRUENCE.

Islamic Beliefs the basics  Journey of life  Purpose to be Allah’s viceroy  Meaning of illness,disability,adversity  Death is a beginning of eternal of life  Time of death preordained; “No human being can die save by Allah’s leave at term preordained” (Q 3:145)  All creation / circumstance in accordance with Allah’s Will.  Muslims total submission and trust in Allah (Tawakul)

Islamic Beliefs cont:  No individual is burdened beyond its capacity to cope  Accountability – for all deeds  Concept of Free Will  Good deeds rewarded many fold  Repentence & Forgiveness “..Despair not of the mercy of Allah, for Allah forgives all sins, for He is Oft Forgiving most merciful.” (Q,39:53)

Islamic Beliefs cont;  Patience (Sabr) “..to those who patiently persevere – who say, when afflicted with calamity: “To Allah we belong, and to Him is our return – they are those on whom (descend) blessings from their Lord, and mercy, and they are the ones that receive guidance” (Q 2: ) “ After hardship comes ease: surely after hardship comes ease” (Q, 94:5-6).  Actions benefiting the deceased Sadaqa: charity Dua: supplication Ongoing blessings / rewards

Assessment  Standard Biopsychosocial Ax  Spiritual Ax How do you make sense of what is going on for you? Are you religious? (What religion are you?) How does Islam guide you in looking at this? How is this way of looking at things helpful? (thoughts, feelings, behaviours) How does this help you cope with the pain? Deal with your stress? What sorts of things do you do that you find helpful in relaxing you?

Islamic Interventions Wudu – ablution  (spiritual / physical cleansing) Initiation / motivation / self-care /refreshing / distraction / diversion  Salat – Prayers 5 times per day Mindfulness / relaxation / decrease physiological arousal / exercise –stretches Recitation of the Quranic verses  Dua –Supplication – direct communication / connection to Allah No intercession needed Zikr- Rememberance of Allah (99 attributes of Allah) eg. Recitation and contemplation of the names illicit same attributes in us. Eg. Saabir, Shaafi, Salamu, Breathing; “Allah Hu”

Community Support Protective Factors Social support – typical of Islamic community Rituals – gatherings, religious service, assisting the family (food, practical assistance), reading of the Quran, Zikr, normalizing death.

Case Study #1 Mona  32 yo mo., 6 ch’n b/w 15 and 2 yrs  Multiple trauma / grief; Eldest – Hodgkin's 12 months of Rx at age 12. Daughter with moderate intellectual disability Displacement – left homeland Jan. ’06 backed van over 3 yo son  Playing the holy shuffle – got it!

Case Study #2  Nargis, 55 years old, married with 3 adult daughters, all married and settled. Had cervical cancer which she survived a decade ago. Oncologist did not order the relevant tests on the latest follow up visit resulting in secondary tumours not being picked up in her abdomen and gut. She collapsed a work a week later then she was taken to hospital and the cancer was discovered. Prognosis was very poor.  Main psychological symptom was anger at oncologist but sense of frustration and injustice when he would not see her.  Also depression because of late detection

Scenarios Irrational Belief “I can’t take this anymore…” Islamic Reframe “..no soul is burdened with more than it can bear…” Irrational Belief “.. I could have saved her, if only…if only…my fault” Islamic Reframe “.. it is Allah’s Will….her time had come..nothing / no one could have prevented it”

Scenarios Irrational Belief “Too late.. Not time to repent…haven’t done enough..I will got to hell..” Islamic Reframe “..Allah loves all those who repent… Oft giving most merciful…” Irrational Belief “.. Why me? I’m being punished… I am bad”. Islamic Reframe “ Illness and suffering cleanses a Muslims soul by diminishing their misdeeds… Allah is testing me… I must be patient… persevere”

Therapist Considerations  Awareness of own sensitivities / biases – resolve them  Don’t be afraid to ask  Convey curiosity, interest, respect  Use Socratic questioning, reflection, summarizing, empathic listening  Illicit self-affirming beliefs

References Psychology from an Islamic Perspective Interest Group (PIPIG);  Books & Articles;  Badri, M (2000). Comtemplation: An Islamic Psychospiritual Study. Madeena Books, KL.  by Salma Yakoub