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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0607-COGNITIVE and SPIRITUAL APPROCHES IN PATIENT-CENTERED COUNSELING FOR ANXIETY

Presentation for the class of Msc Primary Health Care on July 13th, 2006 by Dr Omar Hasan Kasule, Sr. Professor of Epidemiology and Islamic Medicine, Institute of Medicine Universiti Brunei Darussalam

Learning Objectives

  1. Define and classify human drives
  2. Explain the genesis of unpleasant emotions from unsatisfied drives
  3. Define anxiety and its various classifications
  4. Distinguish anxiety from fear and depression
  5. Describe normal anxiety, its manifestations, and its benefits
  6. Describe pathological anxiety, its manifestations, and its complications
  7. Describe how pathological anxiety is related to spiritual malady and cognitive impairment
  8. Describe primary prevention of anxiety disorders by correcting ‘aqidah and undertaking ‘ibadat
  9. Describe secondary prevention of anxiety by removing the stressor in addition to spiritual methods, cognitive methods, and du’a
  10. Describe tertiary prevention of anxiety by socialization and rehabilitation of ‘aqidat
  11. Describe in detail the approach of iman restoration therapy in treating anxiety disorders

Learning Tasks

  1. Reading a 4-page background before class
  2. Discussion of the background reading in class
  3. Discussion of Qur’anic references to anxiety disorders
  4. Discussion of iman restoration therapy

 

1.0 EMOTIONS AND DRIVES

1.1 The heart, qalb, is the seat of emotions. Its emotional states can be expansion, inshiraah; stress, dhiiq; and calmness, tama'aninat.

 

1.2 The basic animal drives are hunger, thirst, sex, self-protection & security, sociability, and inner promptings of the inner self, nafs. The food and sex drives are the strongest and both are necessary for survival of the human species. Humans have drives more and above the animal drives described above: honor, sharaf; altruism, iithhar, faith, iman, consciousness of God, taqwah, seeking the pleasure of God, ridhallah; seeking knowledge, talab al ‘ilm; appreciation of esthetic beauty, and self-actualization.

 

1.3 Drives are inside and emotions are their external manifestations. Satisfaction of drives is associated with pleasant emotions. Dissatisfaction of drives is associated with unpleasant emotions. Drives cannot be denied or abolished but have to be controlled and channeled.

 

1.4 Pleasant emotions are love, hope, elation, tranquility, mercifulness, and empathy.

 

1.5 Unpleasant emotions are fear, rage, aggression, enmity, hate, sadness, despair, laziness, and jealousy.

 

2.0 ANXIETY, karb, dhiiq al sadr, dhank

2.1 Definition

Anxiety is defined as a feeling of dread, fear, or apprehension. It represents breakdown of balance, mizaan. Normal anxiety is a motivator for doing good. Pathological anxiety demotivates and leads to retardation.

 

Anxiety may present as a panic attack when a person suddenly becomes anxious and manifests physiological and psychological symptoms of anxiety for a short time.

 

Anxiety may also present as a phobia which is a form of anxiety focused on a specific object. Phobias are generally irrational but may have an underlying bad past experience. Anxiety may manifest as insomnia, irritability, agitation, nausea, vomiting, diarrhea, urinary frequency, feeling of suffocation, dilated pupils, and rapid breathing.

 

Anxiety is difficult to distinguish from fear and depression. The three share common causative factors and some forms of treatment.

 

In fear there is a logical current or future threat and the response is commensurate.

 

Depression is related to past events and involves sadness and not necessarily fear. Minor depression is usually a reaction to adverse events but major depression may have a biological basis unrelated to any event. Depression is usually not included among emotional disorders; it is classified as a mood disorder.

 

2.2 Normal Anxiety

In normal anxiety the feeling of dread is appropriate to the actual threat or danger and is a positive phenomenon. It can be the basis for correct behavior to avoid the dreaded event. We may also induce anxiety in order to get good conduct for example use fear of hell to make someone pray. Normal anxiety is praiseworthy and represents a high level of behavior in a human when compared to animals. Normal anxiety is needed for the health of the heart otherwise the heart reverts to the states of moral laziness, ghaflat al qalb and moral emptiness, faraagh al qalb both conditions predispose a person to evil.

 

Normal anxiety is closely intertwined with faith. Those with faith are anxious about how correct their relation with the creator is and get worried when they contemplate the consequences of disobeying God. They will be careful to avoid sins. They are anxious because of fear of shame and fear of guilt. Their state of anxiety makes it easier for them to identify their sins and seek repentance, taubat. Anxiety of this nature however severe it may is normal and will lead to positive consequences for the individual and the community.

 

2.4 Pathological anxiety

Anxiety is considered pathological if it is prolonged / recurrent, or when it results in disruption of normal life, or when it has no commensurate and logical justification. Normal anxiety can turn into pathological anxiety if the person fails to deal positively with the cause of the anxiety and spends a lot of time worrying about it. Pathological anxiety is a reflection of either cognitive or spiritual impairment.

 

Cognitive impairment is when the victim fails to understand events in their proper perspective and ends up worrying a lot about them. Pathological anxiety is basically worry and fear that cannot be logically justified.

 

Diseases of the heart underlie most cases anxiety. The lower the level of faith, the higher the level of anxiety.  In the absence of correct faith there is no hope. In the ignorance of pre-determination (qadar and qadha) self-blame occurs leading to anxiety and depression. Not understanding God’s bounties humans worry about one problem and forget that they have a lot of good things for which they should thank Allah. The disease of being anthropocentric, thinking that the human is the center of everything, also contributes to anxiety when a human does not realize that there are some things he cannot do.

 

3.0 PREVENTION AND TREATMENT OF EMOTIONAL DISORDERS

3.1 PRIMARY PREVENTION BY BUILDING FAITH, ‘AQIDAT and WORSHIP, IBADAT

Preventive Approach

Prevention is the best approach to emotional disorders. There are basically 2 preventive measures: correct belief, ‘aqidat, which gives us correct understanding of life’s events and worship, ibadat, which disciplines and strengthens us.

 

Correct aqidat

Correct aqidat gives the potential victim a reality bigger than himself and his problem. The problem suddenly becomes miniscule compared to the big expansive cosmos. Correct aqidat also gives hope, raja, in the mercy and help of Allah. It also teaches the potential victim the value of reliance on God, tawakkul. It teaches us to renounce the material possessions of the earth, zuhd, so that we do not become anxious and depressed when we lose them.

 

Acts of Worship

Acts of worship, ibadat, help humans to maintain balance, mizan, and equilibrium, i’itidaal. Prayer, salat, leads to calmness, sakiinat. Obligatory charity, zakat, involving giving away some of our wealth in charity cures us of the disease of covetousness, shuhhu. Meditation, dhikr & tafakkur, leads to equilibrium. Meditation controls papanca (Buddhist term for monkey mind jumping from idea to idea eventually causing anxiety).

 

3.2 SECONDARY PREVENTION: REBUILD AQIDAT + COGNITIVE + DUA

GENERAL APPROACHES

Eliminating the trigger: Emotional disequilibrium is a disease that must be treated. Every disease has a treatment, li kulli daai dawaau. Once emotional disorders have occurred, the best approach is to remove the cause if it can be identified. Then we undertake the task of rebuilding, repairing, and restoring aqidat. This is supplemented by dua,

 

Restoration of faith, ‘aqidat: The most effective approach to dealing with emotional disorders is to correct the faith. This requires clarifying certain relationships and clarifying the issues of causality. A person must know the correct relation with God, with his own body, with other humans, and with the eco-system. Any defect in any one of these relationships will lead to emotional disequilibrium. Understanding causality removes a big burden of guilt from a person for what has gone wrong. Nothing happens without God’s permission. This however does not remove personal responsibility for actions.

 

Cognitive approach: empirical analysis of the problem may lead us to conclude that it is not worth worrying over. We need to understand that problems are a test, ibtilaa. The final result is not having a problem but knowing how to deal with it. Ignorance of human limitations (physical, cognitive, sensory) makes humans stress themselves over failures. If they were wiser they would not blame themselves because they would known that some tasks are beyond their ability. Human perception is not accurate. What is perceived as a problem may not be a significant problem or may not a problem at all and this would become obvious with passage of time.

 

Supplication, dua

Supplication is very effective in dealing with emotional disturbances. Its effects are dual. On one hand there is supplication to God to relieve the stress. On the other hand there is the feeling of relief because the problem has been referred to a higher and stronger power

 

SPECIFIC APPROACHES

Treatment of anxiety: Treatment of anxiety revolves around identifying the cognitive impairment on which it is based and spiritual approaches to strengthen the person in dealing with the dread. Basically pathological anxiety manifests inability to understand that there are many phenomena or problems that we cannot resolve. It also reflects lack of faith in Allah’s help and sustenance. The victim pretends to be alone and to face the problem unaided which explains why be becomes overwhelmed.

 

Treatment of stress: The quickest treatment for stress is to remove the stressor. This however does not always succeed in returning the person to the normal state because memories of unpleasant stressors may continue eliciting stressful reactions for a longer time. Cognitive approach to stress is to make the person realize that there is no rational basis for the stress over-reaction. Spiritual approaches involve repairing the relation to the Creator so that the victim feels empowered to cope more effectively with the stressor or even ignore it altogether.

 

SYMPTOMATIC APPROACHES

Biochemical treatment: Some individuals are constitutionally predisposed to anxiety and depression. This may reflect basic chemical imbalances that can be corrected by appropriate drugs. Misuse of drugs to treat emotional disorders that are not biological. This is treating the symptoms and not the disease. It represents an escape from reality and refusal to confront difficult situations.

Psychotherapy

 

3.3 TERTIARY PREVENTION / REHABILITATION

After the acute episode we should continue rebuilding aqidat and emphasizing ibadat until the victim is fully rehabilitated.

 

Part of rehabilitation is socialization. Emotional disorders tend to thrive when people are isolated and by themselves. They decrease when victims interact with others and are exposed to a wider range of challenges than the narrow concern with their personal worried.

 

It is natural for humans to be with others. Social isolation is not normal. Being with others tends to distract the victim from worrying about his small problems.

 


4.0 ‘AQIDAT RESTORATION THERAPY by CORRECTING MISUNDEERSTANDING OD QADAR/TAKDIR

4.1 Definition of the concept of qadar

Everything is fixed and is under Allah's pre-determination.

 

The two terms qadha and qadar mean different things. Qadar is pre-determination or pre-fixing of events before their occurrence. Qadha is a term used to refer to the empirical or practical occurrence of what was pre-determined by qadar.

 

In the stage of qadar Allah knows what will happen but the human does not. The human has to struggle as best as he can to achieve a desired objective. In the stage of qadha the event has occurred, the human has to accept what happened because now he can do nothing to reverse the qadar of Allah.

 

Allah’s knowledge and will are unrestricted. Humans have to surrender to Allah’s will. They cannot change established qadar except by dua.

 

Belief in qadar is associated with contentment of the heart, avoidance of excessive joy and sadness, bravery and initiative, and lack of fear.

 

There is no escape from qadar since it operates everywhere. Everything was pre-determined before the creation of the earth and the heavens and is recorded in Allah’s great record. All phenomena and events in the universe follow the program in the record.

 

 Ordinary humans have no way of knowing what is in the record. Qadar It is part of belief in the unseen because human intellect can not on its own logically work out all aspects of qadar.

 

 

 

4.2 Will, iraadat, knowledge, ‘ilm, and power, qudrat

Allah’s knowledge, will, and power are unlimited. Human will, knowledge, and power are limited. The limited human will can be misguided by shaitan.

 

A human in the course of normal life gets good and bad experiences. A believing Muslim knows that all is part of qadar and says ‘praise be to Allah’, alhamdu li llaah, for both good and bad experiences. The terms good and bad in human experience and knowledge are relative. What may appear to be good may turn out to be bad. What may appear to be bad may turn out to be good.

 

4.3 Human action

All human actions were created by Allah. He knows the actions of humans in advance. Allah tries humans by letting them be free in the choice of their actions but He knows in advance what they will choose. Whatever choices the human makes Allah is forgiving and is kind.

 

Free will entails responsibility and humans are responsible for their actions and are accountable for their choices. Humans should not give up struggling relying on qadar and arguing that everything is pre-determined. They have to make all the efforts that is humanly possible to achieve a good result.

 

The laws of causality are fixed such that an action is inevitably followed by the predictable result unless there is special divine intervention. However despite all human effort the results turn out different from the expectation, the human must submit and accept the will of Allah.

 

A human can be guided or misguided. Guidance in the long run is from Allah. Humans within their limited will can exert effort to be guided. All of the human’s life on earth is a great test of how well the free will is used.

 

4.4 Causality and causal relations

In most human situations phenomena follow the fixed causal laws ie action is followed by an effect. Each event has a cause, sabab. All causes are from Allah. The causal laws are called ‘sunan Allah fi al kawn’ in Qur’anic terminology. These laws are fixed and are stable. Allah is not bound to obey these laws because they are His laws. His will is above them and can alter them.

 

Allah created the causes and the effects. Thus causes are part of qadar. Normally the cause is followed by the expected result. There are however situations such as prophetic miracles in which divine intervention breaks those physical laws known to humans. In such situations one qadar is reversing another qadar.

 

4.5 Misunderstanding of qadar

Correct understanding of qadar requires distinguishing tawakkul that is good from tawaakul that is bad. Tawakkul in relying on Allah after taking all the necessary measures to achieve an objective following the laws of causality. Tawaakul is giving up all effort and just wait for things to happen. Human illness is part of qadar. Medical treatment is not denial of or attempting to reverse qadar. Both the disease and its treatment are part of Allah’s all-embracing qadar. The human in his limited knowledge can not distinguish between curable and incurable disease. He therefore plays safe by treating all diseases to the best of their ability being fully aware that this is an attempt and leave the rest to Allah. Allah alone determines the life and death. No human can give life or take it away. The human can be involved as an agent but not as a cause. These are matters of qadar that the human intellect cannot understand fully. Trying to search into such matters leads to perdition. It is therefore advised not to go deep in matters of qadar.

Professor Omar Hasan Kasule June 2006