Exploring the role of Islam in perceptions of mental illness in a sample of Muslim psychiatrists based in Johannesburg

Background . Western definitions of, and approaches to, mental illness have been critiqued for their lack of incorporation of cultural and spiritual elements. Objective. To explore perceptions of mental illness, particularly in terms of the role of Islam in the understanding of mental illness among South African Muslim psychiatrists practising in Johannesburg. Methods . Using a qualitative design, semi-structured interviews were conducted with a convenience sample of 7 Muslim psychiatrists in the Johannesburg area. Thematic content analysis was used to analyse the transcribed data. Results. Psychiatrists subscribe to a more biomedical model of illness. The findings of this study also suggest that psychiatrists attempt to remain objective and to refrain from imposing their religious and cultural beliefs on their patients. However, their conceptualisation of mental illness is influenced by their religion and culture. Furthermore, all participating psychiatrists indicated that they always draw on Islamic values when treating their patients. Issues of cultural competence were also highlighted. Psychiatrists indicated that they were open to collaboration with traditional healers and psychologists but that this was quite challenging. Conclusion . The necessity for formal bodies to develop routes for collaboration between healthcare professionals and traditional healers was brought to the fore. So, too, was the need to incorporate indigenous theory and knowledge into mainstream definitions and approaches to mental illness.

The current editions of both the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR [1] and the International Classification of Diseases (ICD-10) [2] define mental illness in terms of the existence of a clinically recognisable set of symptoms or behaviours associated with interference with personal functions.Across the world there are individuals whose patterns of aberrant behaviour and experiences may not fit any into any of these Western conventional definitional and diagnostic categories, yet these patterns are considered 'illnesses' in a specific population or cultural group. [3]Some of these behaviours are labelled as culture-bound syndromes and have recently been recognised in the DSM-IV-TR, but this remains an underdeveloped area.As such, there is a need to broaden aetiological understandings and incorporate them into diagnoses and treatments, in order to understand and treat patients from non-Western backgrounds adequatley. [3]This study explored perceptions of mental illness among a group of Muslim psychiatrists in the Johannesburg region.

Conceptualising illness in Islam
Islamic perspectives on illness have been developing for centuries [4] and can be traced to the Quran itself. [5]Within the Quran, four components are mentioned that have come to be viewed as a holistic model of the self. [6][7] In order to be healthy, all 4 aspects of the self need to be balanced.An imbalance in any aspect results in physical, mental and/or spiritual illness. [3,6]Islamic understandings of mental and physical illness correspond to currently accepted diagnostic classifications as described in the DSM-IV-TR [1] and the ICD-10. [2]Islam, however, acknowledges an additional category of illnesses: spiritual illnesses, which are broadly divided into 2 types, sihr (black magic) and nazr/ayn al husood (evil eye). [3]inn, spirit possession and bewitchment all fall under the category of sihr.Nazr, on the other hand, is when a person looks at another person with an 'evil eye' or with envy.When a person has nazr they suffer from certain symptoms.For example, things do not seem to work out for them in personal or business ventures or they undergo changes in appetite.However, people who suffer from spiritual illnesses caused by sihr present with more severe symptoms, leading to more profund and destructive disturbances in physical, mental and spiritual well-being.Sihr needs to be treated by traditional healers. [3]

Treatment of illnesses in Islam
Ally and Laher [3] say that within the Islamic religion, moulanas and/or sheikhs are considered the traditional source of healing.Asefzadeh and Sameefar [8] emphasise that even in countries with practising physicians, Muslims continue to consult Islamic traditional healers.
Islamic traditional healing practices cover a wide range of remedies.Treatments for medical conditions include herbal remedies, massage therapy and cupping. [6]Treatments for mental illness may include Background.Western definitions of, and approaches to mental illness have been critiqued for their lack of incorporation of cultural and spiritual elements.Objective.To explore perceptions of mental illness, particularly in terms of the role of Islam in the understanding of mental illness among South African Muslim psychiatrists practising in Johannesburg.Methods.Using a qualitative design, semi-structured interviews were conducted with a convenience sample of 7 Muslim psychiatrists in the Johannesburg area.Thematic content analysis was used to analyse the transcribed data.Results.Psychiatrists subscribe to a more biomedical model of illness.The findings of this study also suggest that psychiatrists attempt to remain objective and to refrain from imposing their religious and cultural beliefs on their patients.However, their conceptualisation of mental illness is influenced by their religion and culture.Furthermore, all participating psychiatrists indicated that they always draw on Islamic values when treating their patients.Issues of cultural competence were also highlighted.Psychiatrists indicated that they were open to collaboration with traditional healers and psychologists but that this was quite challenging.

Conclusion.
The necessity for formal bodies to develop routes for collaboration between healthcare professionals and traditional healers was brought to the fore.So, too, was the need to incorporate indigenous theory and knowledge into mainstream definitions and approaches to mental illness.Corresponding author: S Laher (sumaya.laher@wits.ac.za) herbal remedies, massage therapy, taa'weez (amulets with Quranic verses), water over which verses of the Quran are read, and special zikr and duas (prayers).Treatment for spiritual illnesses includes taa'weez, water over which verses of the Quran are read, special zikr and duas (prayers), burning lobaan (frankincense) or other natural substances, and/or using herbal remedies to ease physical symptoms. [3,6]Ally and Laher [3] state that Islamic traditional healers try and treat spiritual aspects of illness by removing the effects of sihr or nazr using any combination of treatments mentioned above.However, they also noted that if psychological or medical symptoms are present, assistance from a psychologist or doctor may be necessary.Islamic traditional healers have value in that they contribute to the treatment of physical, mental and spiritual illness, and thus to mental health and well-being.

Cultural competence
Part of the public's persistent adherence to traditional healing may be linked to cultural competence.Laher and Khan [7] state that being aware of and addressing cultural and religious beliefs is an important part of providing quality care to individuals with mental illness, as these aspects may provide a framework for understanding mental illness.They found that patients were open to Western forms of treatment, but still preferred to be treated by someone they believed was competent in their understanding and knowledge of their culture.It was also noted that cultural competency puts patients at ease. [7]These ideas may be related to the concept of culture-matching as highlighted by Haarmans, [9] which refers to matching a clinician with a patient based on their racial/ ethnic identity.The belief is that this 'matching' will increase cultural competency and therefore therapeutic outcomes.
There is a counter-argument which suggests that in cases of cultural similarity, the therapist may make unjustified assumptions about the patient, or ignore or fail to explore certain material because its implications seem self-evident. [10]Padayachee and Laher [11] reported that Hindu clients prioritised the fear of stigma and damage to social standing due to confidentiality concerns, rather than the value of cultural competence.Another consideration is the historical inequalities in the South African context, which make it difficult to ensure culture-matching for clients.However, cultural competency is possible among all practitioners and, despite the drawbacks, there is value in encouraging it, as it facilitates both the training of emerging practitioners from different cultures and religions and the treatment of clients with a religious or spiritual orientation.
Given that most psychiatrists (Muslim and other) are trained within a predominantly Western paradigm, which gives primacy to a more empirical, biologically based model of illness, research of the type undertaken in this study is essential.This study explored perceptions of mental illness in a sample of Muslim psychiatrists, in order to distinguish the ways in which these religious and cultural perceptions may influence a practitioner's diagnosis, treatments and personal views of mental illness, thereby hoping to inform and transform the dominance of one particular, overarching epistemology.

Sample
A convenience sample consisting of 7 Muslim psychiatrists (3 male, 4 female) was interviewed.It should be noted that the pool of Muslim psychiatrists in Johannesburg is not big.Although 14 psychiatrists were approached, only 7 consented to be interviewed.Three of the participants had practised as medical practitioners prior to entering the field of psychiatry, and 1 had also worked in public health medicine.Four had been qualified for less than 5 years while the other 3 had been involved in the field of psychiatry for 10 -20 years.All participants worked in the public sector, while 3 stated that they worked in both the private and public sectors.Of the 7 participants, 6 consulted with both male and female patients, while 1 consulted mainly with females.The participants consult with patients from various religious and cultural affiliations.

Instruments
Semi-structured interviews were conducted.The final interview schedule was divided into 6 sections: • contextual factors • the psychiatrist's perceptions of mental illness • treatment of mental illness • collaboration between practitioners • cultural and religious factors and their influences on the conceptualisation of mental illness • the concept of spiritual illnesses.

Procedure and data analysis
Ethical clearance was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (HONS/11/037IH).Psychiatrists were approached and those willing to participate were interviewed within the timeframe of the study.Interviews were transcribed and analysed.Thematic content analysis was conducted as per the steps outlined by Braun and Clarke. [12]

Results and discussion
Four themes were identified from the interview data: • How mental illness is understood from a psychiatrist's perspective • The role of religion and culture in understanding mental illness • Aspects of the psychiatrists' conflict regarding their desire to remain objective and conform with Western psychiatry, v. the influence of their culture and religious beliefs on the manner in which they perceive and treat mental illness • The psychiatrist's views on collaborating with traditional healers and psychologists.

Understanding mental illness
The way in which participating psychiatrists perceive mental illness is congruent with the definition of mental illness provided by the DSM-IV-TR and the ICD-10.Although the participants did not include all aspects of these seminal texts in their definition, all subscribed to their general ideas.There was also a strong emphasis on biological factors such as organic dysfunction or chemical imbalances in participants' responses.This is congruent with the training that psychiatrists receive, which is predominantly located in the biomedical model of disease.Less reference was made to environmental and socio-cultural aspects and even less to the religious aspect.This links to the conflict (discussed later on) that was evident between the psychiatrists' personal position and beliefs and their need to conform to the dominant Western paradigms within which they were trained.

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Afr J Psych 2013;19(2):52-54.DOI:10.7196/SAJP.396Exploring the role of Islam in perceptions of mental illness in a sample of Muslim psychiatrists based in Johannesburg T Bulbulia, BA (Hons); S Laher, PhD Department of Psychology, University of the Witwatersrand, Johannesburg, South Africa