Exploring the role of Islam in perceptions of mental illness in a sample of Muslim psychiatrists based in Johannesburg.
Conceptualising illness in Islam
Islamic perspectives on illness have been developing for centuries  and can be traced to the Quran itself.  Within the Quran, four components are mentioned that have come to be viewed as a holistic model of the self.  This model is based on the interrelation between the ruh (soul), the qalb (connection between the soul and the body), the aql (intellect) and the nafs (drives or desires) merging through the dahmeer (consciousness). [5-7] 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  and the ICD-10.  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). 
Jinn, 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. 
Treatment of illnesses in Islam
Ally and Laher  say that within the Islamic religion, moulanas and/or sheikhs are considered the traditional source of healing. Asefzadeh and Sameefar  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.  Treatments for mental illness may include herbal remedies, massage therapy, taaWeez (amulets with Quranic verses), water over which verses of the Quran are read, and special zikr and duas (prayers). Treatment for spiritual illnesses includes taaweez, 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  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.
Part of the public's persistent adherence to traditional healing may be linked to cultural competence. Laher and Khan  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.  These ideas may be related to the concept of culture-matching as highlighted by Haarmans,  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.  Padayachee and Laher'111 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.
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.
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. 
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 DSMIV-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.
Religion and culture
The majority of participating psychiatrists (n = 5) stated that their religion and culture influenced the way in which they perceived mental illness. This is in accordance with Dell,  who highlights that culture, ethnicity, religion and spirituality are important influences on this perception. Although the manner in which religion and culture influenced the participants differed, they all seemed to reflect the idea that Islam is a way of life, which infiltrates all aspects of behaviour: they stated that the values in which they believed stemmed from their religion and culture and that this influenced the way in which they treated their patients. All participants also believed that Islam does acknowledge mental illness, as individuals experiencing mental illnesses are mentioned in the Quran.
This is in accordance with the literature reviewed, which highlights that centuries of Islamic scholars (e.g. Al Kindi, Al Ghazali, Rhazes, Avicenna and Averroes) built their theories of medicine and psychology around a framework based on teachings from the Quran and the Hadith.  It is also interesting to note that the first dedicated psychiatric hospitals were founded in the early 9th Century by Muslims in Baghdad. This was followed by a second hospital in Cairo towards the end of the 9th century. 
Participants emphasised the role of spiritual aspects when commenting on Islamic definitions of mental illness. This link was made by all of the participants, who explained that being possessed by jinns, being bewitched or having being affected by nazr are common beliefs among patients from the Muslim community. Ally and Laher  explained that possession and the existence of jinn form part of the culture of Islam. In accordance with Ally and Laher,  most participants believed that in the Islamic religion faith healers attempt to remove evil spirits or nazr through various methods.
The 'objective' psychiatrist
This theme had two sub-themes, namely (i) the conflict within the psychiatrists, in terms of their desire to remain objective and their tendency to be influenced by their religious and cultural beliefs, as well as (ii) issues of cultural competence. Participants emphasised that they did not want their beliefs to influence their approach to mental illness, particularly in the sense that they did not want to impose their religious beliefs on their patients. This is in accordance with McLeod,  who states that a counsellor needs to be capable of remaining uninfluenced by his/her own beliefs and attitudes when treating a client. However, it was evident that the participants' religious and cultural beliefs did influence them to a certain extent and further research is warranted on this conflict and how it is handled by therapists, and what the way forward would be.
Participants also drew on Islamic values such as honesty, respect and compassion, and mentioned remaining non-judgmental. These aspects are highlighted by McLeod,  who explains that principles such as remaining objective, respectful, sincere and honest are fundamental in any counselling relationship. As such, these values are important for all ethically orientated practitioners, not solely psychiatrists and not only Muslims.
The majority (n = 5) of the participants stated that sharing religious or cultural beliefs with their patients seemed to create a deeper sense of understanding. This concept was also advanced by Padayachee and Laher,  who found that Hindu psychologists felt that they were able to relate better to Hindu patients. These findings seem to emphasise concepts such as culture-matching.
Sharing the field: Collaboration with other practitioners
Most (n = 6) of the participants were open to collaborating with traditional or faith healers, as long as this was in the best interest of the patient. However, many of them (n = 5) stated that they had not done so in the past. This demonstrates that communication channels between traditional healers and medical practitioners rarely exist or have not been adequately developed. Therefore, developing these channels may carry significant benefits, and could increase psychiatrists' knowledge of traditional healers' practices. It would also allow traditional healers to become more aware of medical treatments for mental illness, which may prevent them from administering treatments that could interfere with the patient's medication or be harmful to the patient.
All participants were open to collaborating with psychologists and viewed the role of the psychologist as essential to the treatment and management of mental illness.
This study showed that religion and culture influenced the interviewed psychiatrists' perceptions and treatment of mental illness. They acknowledged the influence of the spiritual aspects that their culture attributes to mental illness, in addition to biological and psychological dimensions. This suggests that mainstream psychiatric models may need to expand their definitions of, and approaches to, mental illness to include more religious and cultural dimensions, which may add cultural validity to the taxonomy of illness and make for more culturally competent practitioners.
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T Bulbulia, BA (Hons); S Laher, PhD
Department of Psychology, University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: S Laher (firstname.lastname@example.org)
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|Author:||Bulbulia, T.; Laher, S.|
|Publication:||South African Journal of Psychiatry|
|Date:||Jun 1, 2013|
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