Religiously Integrated Psychotherapy With Muslim Clients: From Research to Practice

Professional Psychology: Research and Practice 2010 American Psychological Association 2010, Vol. 41, No. 2, 181 188 0735-7028/10/$12.00 DOI: 10.1037/a0017988 Religiously Integrated Psychotherapy With Muslim Clients: From Research to Practice Hisham Abu Raiya Sachnin, Israel Kenneth I. Pargament Bowling Green State University In this paper, we attempt to translate empirical findings from a program of research that developed a Psychological Measure of Islamic Religiousness (PMIR) into practical clinical applications. The findings from this program of research are complemented and illuminated by findings from other empirical research and clinical work with Muslims. Our recommendations can be summarized as follows. First, clinicians should inquire directly about the place of religion in the lives of their Muslim clients. Second, mental health professionals should ask about what Islam means to their clients and educate themselves about basic Islamic beliefs and practices. Third, clinicians should help their Muslim clients draw on Islamic positive religious coping methods to deal with stressors. Fourth, we recommend that clinicians assess for religious struggles, normalize them, help clients find satisfying solutions to these struggles and, if appropriate, refer clients who struggle to a Muslim pastoral counselor or religious leader. Finally, in order to overcome stigma associated with mental health issues, mental health professionals should educate the Islamic public about psychology, psychopathology, and psychotherapy. Keywords: Muslims, religiously integrated psychotherapy, empirical research, positive religious coping, religious struggle, stigma, mental health HISHAM ABU RAIYA received his PhD in clinical psychology from Bowling Green State University. Recently he completed a 1-year fellowship in clinical psychology at the Counseling and Behavioral Health Services, New York University. His area of research is the psychology of religion, especially the psychology of Islam. He has conducted multiple research projects and published several articles and book chapters pertaining to this field of inquiry. KENNETH I. PARGAMENT received his PhD in clinical psychology from the University of Maryland. He is professor of psychology at Bowling Green State University. His research interests focus on the interface between religion, spirituality, stress, and coping and the development and evaluation of spiritually integrated interventions. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Hisham Abu Raiya, P.O. 1277, Sachnin, Israel. E-mail: aburaiya@gmail.com Recently, the field of psychology has shown a growing interest in the impact of religious beliefs and practices on the psychological well-being of the individual. It is clear that religious practices and beliefs are prevalent in many countries around the world and are associated with indices of health and well-being (Koenig & Larson, 2001; Spilka, Hood, Hunsberger, & Gorsuch, 2003) and religion serves as a valuable tool for individuals dealing with life stressors (Pargament & Abu Raiya, 2007). Researchers and practitioners have also begun to convert this body of knowledge into religiously integrated psychotherapy with clients, with promising results (e.g., Pargament, 2007; Richards & Bergin, 2005). However, this research and the practical applications derived from it have focused almost entirely on Christian populations and largely neglected people from other traditional faiths, Muslims in particular (Abu Raiya, Pargament, Mahoney, & Stein, 2008). Despite the fact that Islam represents the fastest growing religion in the United States and the World (U.S. State Department, 2001), systematic, rigorous, and large-scale scientific psychological research on members of this diverse population has been sparse. Therefore, mental health professionals lack a clear picture of the ways Islam influences the lives of its followers. Historically, the psychology of Islam has relied almost exclusively on clinical observations, theological speculation and anthropological methods of inquiry (Abu Raiya, Pargament, Stein, & Mahoney, 2007). Drawing on this base, a few models have been proposed that incorporate Islamic religious elements into psychotherapy (e.g., Ali, Lui & Humedian, 2004; Carter & Rashidi, 2003; Dwairy, 2009; Mehraby, 2003). For example, working with Asian Muslim immigrant women in the United States, Carter and Rashidi (2003) developed a theoretical model of psychotherapy for Muslim women suffering from mental illness. Their model incorporates Western therapeutic elements, Eastern philosophical principles (e.g., low expectation, humility, external locus of control) as well as Islamic practices and beliefs (prayer, reading the Qura n, sayings of the prophet Muhammad). A few empirical studies have found that different forms of religious psychotherapy are effective with Muslim clients who suffer from anxiety, depression, and bereavement (Azhar & Varma, 1995a; Azhar & Varma, 1995b; Azhar, Varma & Dharap, 1994; Razali, Aminah & Khan, 2002; Razali, Hasanah, Aminah & Subramaniam, 1998). For example, Razali et al. (1998) worked with a sample of Malay individuals who suffered from either anxiety or depression. Participants were randomly assigned to either a control or a study group. Both groups received standard treatment (medication, supportive psychotherapy and relaxation exercises) for their condition, but the study group received additional religious-sociocultural psychotherapy based on Islamic principles (i.e., prayer, expressing repentance and forgiveness, relying on Allah and supplicating to Him in times of needs). Clients in the group receiving additional psychotherapy that included Islamic 181

182 ABU RAIYA AND PARGAMENT components responded significantly faster to therapy and manifested better adjustment than those receiving standard treatment. Important as these attempts to incorporate Islamic practices and beliefs into psychotherapy are, they are limited in one key respect. Most of these attempts are theoretically or theologically driven; psychoreligious interventions that are based on empirical findings are in short supply. One of the reasons for the absence of empirical research on Islamic religiousness and their links to health and well-being may be the unavailability of valid and reliable measures of Islamic practices and beliefs (Abu Raiya et al., 2008). Recently, a few promising attempts have been made to develop scales of this nature (e.g., Abu Raiya et al., 2008; Ghorbani, Watson, & Shahmohamdi, 2008; Jana-Masri & Priester, 2007; Khan & Watson, 2006; Tiliouine, Cummins, & Davern, 2009; Wilde & Joseph, 1997). Collectively, this emerging body of research has underscored the centrality of Islam to the lives of Muslims and identified clear connections between Islamic beliefs and practices and the well-being of Muslims. However, this body of research has not as yet been integrated into treatment. Between 2004 and 2006, Abu Raiya et al. conducted a threestage program of research with the aim of developing and validating a valid and reliable measure of Islamic beliefs, practices and teachings. The outcome of these efforts was a Psychological Measure of Islamic Religiousness (PMIR). Elsewhere, the process of developing and validating the PMIR (Abu Raiya et al., 2007, 2008) in a sample of Muslims was thoroughly described. In this paper, we translate our findings, and other relevant empirical findings into practical clinical applications. In what follows, we first define the key constructs of our paper, namely religion and religiously integrated psychotherapy. Then, we briefly describe the process of the development and validation of the PMIR. Next, drawing on our work and that of other researchers, we provide several empirically-based concrete recommendations to facilitate the work of mental health professionals with Muslim clients. We conclude by suggesting directions for further empirical studies that might enhance practice in this area. Definitions of Key Constructs Social scientists and theologians have offered numerous definitions of religion, but have failed to reach a consensus (Yinger, 1967). Here we offer a definition of religion that is relevant to the phenomenon of interest- health and well-being. According to Pargament (1997), religion is a search for significance in ways related to the sacred (p. 32). This perspective is tailored to the psychological venture, excluding ontological concerns about the reality of the sacred that go beyond the province of the field. This definition includes two important elements: search and sacred. The search refers to a process of discovery of significant ends in life, conservation of those values once they have been found, and transformation of significance when internal or external pressures require a change (Pargament, 1997, 1999). The search can also be understood in terms of the multiple pathways people take to reach their goals and the goals themselves. Religious pathways encompass a variety of dimensions: ideological, ethical, ritual, emotional, and social. These pathways can lead to diverse goals, including personal ends, such as meaning in life and selfdevelopment, and social ends, such as intimacy with others and justice in the world. What lends religious pathways and destinations their distinctive character is the involvement of the sacred in these means and ends. According to Pargament and Mahoney (2005), the sacred refers not only to divine beings, higher powers, God, or transcendent reality, but also to other aspects of life that take on extraordinary significance by virtue of their association with the divine. Sacred objects can be psychological (e.g., identity, meaning), social (e.g., community, love), time (e.g., Sabbath), people (e.g., leaders), and place (e.g., nature, churches). Because Pargament s definition of religion is applicable to people of different faiths and attends to the rich, multi-dimensional character of religious life, it provided the conceptual foundation for the development of the PMIR. Given that religion plays a central part in the lives of many people, several researchers have argued for the utilization of religiously integrated psychotherapy (e.g., Pargament, 2007; Richards & Bergin, 2005). Religiously integrated psychotherapy is an approach to treatment that acknowledges and addresses the roles religion can serve in the lives of the client, the therapist and the process of change (Pargament, 2007). It should be noted that religiously integrated psychotherapy is different from pastoral counseling though both forms of help address the religious dimension at times, but with a different, albeit related, ultimate goal. Pastoral counseling is counseling provided by a legitimated leader (e.g., priest, imam, rabbi) of a faith community and it focuses mainly on the spiritual health of clients. The primary focus of religiously integrated psychotherapy, on the other hand, is clients mental health and is not provided in an explicitly religious context. The Development of the PMIR and Basis of Clinical Recommendations Between 2004 and 2006, Abu Raiya et al. (2008; see also Abu Raiya, 2006; Abu Raiya, 2005; Abu Raiya et al., 2007) conducted a three-stage program of research with the aim of developing and validating a comprehensive, multidimensional, theoretically based, valid, and reliable measure of Islamic beliefs and practices. The purpose of the first stage was the identification of dimensions of Islam that are potentially relevant to the physical and mental health of Muslims. Toward this end, the researchers reviewed research in the psychology of religion in general and the Islamic literature in particular (Islamic theology and research conducted among Muslims), and conducted in-depth, semi-structured interviews with 25 Muslims recruited in Israel and the United States. In the second stage, the researchers developed an initial measure of Islamic beliefs and practices and pilot tested it using a sample of 64 Muslims recruited in the United States and Israel. The results of this stage showed that the subscales of the measure were relevant to Muslims and demonstrated desirable variability and reliability. In the third stage in the development of the PMIR, the researchers factor-analyzed the PMIR and tested its links to various indicators of physical health and psychological well-being. Toward this end, they used a sample of 340 Muslim participants who completed an online survey of the study, 60.8% of which were women with an average age of 31.74 (SD 8.48, range 18 62). Two hundred and five (60.8%) participants reported being single and 92.9% of them indicated having more than 12 years of education. One hundred and eighty one (53.9%) participants specified

RELIGIOUSLY INTEGRATED PSYCHOTHERAPY WITH MUSLIMS 183 North America as their continent of current residence, 60 (17.9%) reported living in Europe, 50 (14.9%) indicated residing in Asia, 24 (7.1%) reportedly lived in Africa, and the remaining 20 (5.9%) in Australia. Participants indicated moderate levels of self-rated religiousness (M 3.23, SD 1.01; range: 1-5) and self-rated spirituality (M 3.65, SD 1.02; range: 1-5). It should be noted that despite the fact that the researchers were able to recruit Muslim participants from all over the world, this does not ensure that a representative sample was obtained. Future research should use larger and more diverse samples to increase the generalizability of the findings of this study and further strengthen the clinical recommendations described in this paper. The ultimate outcome of Abu Raiya et al. s (2008, 2007, 2006, 2005) program of research was the PMIR which yielded seven factors that demonstrated desirable variability, and discriminant, convergent, predictive, and incremental validity using multiple mental and physical health criterion variables. In the process of developing the measure, the authors also gained multiple insights that have practical clinical implications. The substantial quantitative findings of the third stage of this program of research are the major basis of our clinical recommendations, and are presented throughout the manuscript. These quantitatively based findings are supplemented and elaborated by qualitative information gleaned from the first stage of this program of research, findings of relevant empirical studies conducted by other researchers, and clinical examples from the experience of the first author as a psychotherapist working with Muslim clients. Clinical Recommendations Based on the abovementioned sources of information, we draw the following five major practical recommendations that mental health professionals can use in their work with Muslim clients. Islam Is Central to the Lives of Muslims: Inquire About It! It seems clear that Islam is deeply embedded in the lives of many Muslims. For example, Abu Raiya et al. (2008) found that most of their study s participants reportedly adhered to different Islamic beliefs and ethical conduct, adopted various Islamic religious attitudes, and observed a diverse array of Islamic religious practices. Further, Islam plays a central role in the well-being of Muslims as it is linked to every domain in their lives: mental, spiritual and physical (Abdel-Khalek & Naceur, 2007; Abu Raiya et al., 2008; Ghorbani et al., 2008; Tiliouine, Cummins, & Davern, 2009). Similar to other faiths (Pargament, 1997), Islam serves a variety of functions, such as the provision of comfort, meaning, identity, spirituality, and community. For instance, Abu Raiya et al. (2008) found that the different subscales of the PMIR were associated with diverse indices of well-being including Satisfaction with Life, Positive Relations with Others, Purpose in Life, Physical Health, Alcohol Use, Depressed Mood, and Angry Feelings. Similarly, Tiliouine et al. (2009) developed the Islamic Religiosity Scale (IRS) using a sample of Muslims from Algeria. They found that the two factors of the scale (i.e., Religious Practices, Religious Altruism) predicted multiple well-being indices (e.g., satisfaction with life, physical health, optimism). A few comments of interviewees illustrate the centrality of Islam to many Muslims: Islam is my life. I cannot imagine myself without Islam; My biggest source of pride is being a Muslim. I feel proud that Allah is my one God, Muhammad is my prophet and example, and the Holy Qur an is my book; I suffered a lot from psychological problems like depression and anxiety. When I began practicing Islam, I figured out a lot of mechanisms that can relieve my pain. Nothing heals like Islam (Abu Raiya, 2005). Given the centrality of Islam to many Muslims, mental health professionals should invite Muslim clients into a religious conversation by explicitly inquiring about the place of religion in their lives. This invitation should be offered in the assessment phase, but it may be re-offered at other points in the course of psychotherapy. Three questions are particularly useful in the intake session: 1. Do you consider yourself a religious or spiritual person? If so, in what way? 2. Has your problem affected you religiously or spiritually? If so, in what way? 3. Has your religion or spirituality been involved in the way you have coped with your problem? If so, in what way? These three questions assess the salience of religion to the client, to the problem, and to the solution, respectively (Pargament, 2007). Consider the following example. Recently, the first author started seeing Hadia 1 for counseling. Hadia is a 21 year-old Muslim woman of Asian decent who presented with anxiety symptoms, relationship issues and self-esteem concerns. In the first session, after exploring her presenting problem in detail, the first author (H.A.R.) asked her whether she considered herself a religious or spiritual person. The question seemed to come as a surprise to Hadia who remained silent for a few moments after which she said: I was in counseling before but my therapist never asked me about this and I did not feel comfortable talking about my religious concerns. The fact that Hadia was asked directly about her religiousness from a therapist who seemed genuinely interested in these aspects of her life, led her and H.A.R. to a short, yet meaningful conversation, about the religious struggles that were adversely affecting her psychological well-being. At the end of the session, when H.A.R. inquired about her experience in their meeting that day, Hadia replied: I felt very good...ifelt relieved that you asked me about my religious concerns...nobody asked me about that before... By inviting clients to engage in a religious conversation, therapists open the door to a deeper and potentially more meaningful therapeutic dialogue, one that may have important implications for clients psychological health and well-being. This point holds particularly true for Muslim clients who may be especially likely to embed religion in their lives. Conversely, sidestepping this issue in treatment may lead to an incomplete and even distorted picture of the lives of Muslim clients. Furthermore, by overlooking the religious dimension, therapists may be overlooking vital issues and valuable resources for effective treatment. Islam Is Multidimensional: Ask What It Means, Know What It Is! Like Christianity (Glock & Stark, 1962), Judaism (Lazar, Kravetz & Frederich-Kedem, 2002), and Hinduism (Tarakeshwar, 1 Names and other identifying information of clients mentioned in this manuscript were modified to ensure their anonymity and confidentiality.

184 ABU RAIYA AND PARGAMENT Pargament, & Mahoney, 2003), Islam is a multidimensional religion. For example, the PMIR yielded seven distinct and reliable factors (An illustrative item of each factor is provided in parenthesis): Islamic Beliefs ( I believe in the Day of Judgment ); Islamic Ethical Principles and Universality ( I consider every Muslim in the world as my brother or sister ); Islamic Religious Struggle ( I find myself doubting the existence of afterlife ); Islamic Religious Duty, Obligation, and Exclusivism ( How often do you pray? ); Islamic Positive Religious Coping and Identification ( When I face a problem in life, I read the Holy Qura n to find consolation ); Punishing Allah Reappraisal ( When I face a problem in life, I wonder what I did for Allah to punish me ); and Islamic Religious Conversion ( All at once, I felt that my life has no meaning without Islam ) (Abu Raiya et al., 2008). In a similar vein, Wilde and Joseph (1997) found that their Muslim Attitudes Towards Religion scale was composed of three factors: Personal Help (e.g., I find it inspiring to read the Qura n ), Muslim Worldview (e.g., I think the Qura n is relevant and applicable to modern days ) and Muslims Practices (e.g., I pray five times a day ). Jana-Masri and Priester (2007) identified two factors in their Religiosity of Islam Scale (RoIS): Islamic Beliefs (e.g., I believe that the final and complete religion is Islam ) and Behavioral Practices (e.g., I pray five times a day ). The variety in numbers and content of dimensions that emerge from studies of Muslims may reflect the different interests and goals of the researchers. For example, the RoIS is a relatively brief, efficient index of Islamic beliefs and practices. The Wilde and Joseph (1997) scale includes attitudinal questions about Islam unlike the PMIR which emphasizes the importance of distinguishing between Islamic beliefs and practices and the outcomes of these beliefs and practices. Because it is multi-faceted, Islam can mean different things to different people. It is particularly important then to ask Muslim clients what does Islam mean to you? Mental health professionals who work with Muslim clients should also educate themselves about the basic tenets, practices and beliefs of Islam. These beliefs and practices have been associated with mental health among Muslims (Abu Raiya et al., 2008; Ghorbani et al., 2008; Khan & Watson, 2006; Tiliouine et al., 2009; Wilde & Joseph, 1997). Further, Muslims are one of the most misunderstood groups in the United States. The lack of understanding of and information about Islam might lead to biases in therapy with Muslim clients (Ali et al., 2004). A basic understanding of Islamic doctrine then may be a prerequisite to better communication between psychotherapists and Muslim clients and the administration of culturally and religiously sensitive psychotherapy. To increase their knowledge of Islamic practices, beliefs and teachings, the readers are referred to Esposito (1998). For a description of Islamic religious dimensions that are potentially relevant to the psychological well-being of Muslims, see Ali et al. (2004) and Abu Raiya (2006). Draw on Islamic Positive Methods of Coping: They Are Invaluable Resources Empirical studies have shown that positive religious coping plays a beneficial role in the lives of Muslims coping with major life stressors (Abu Raiya et al., 2008; Aflakseir & Coleman, 2009; Ai, Peterson, & Huang, 2003; Khan & Watson, 2006). According to Pargament, Koenig, and Perez (2000), positive religious coping methods reflect a secure relationship with God, a belief that there is a greater meaning to be found, and a sense of spiritual connectedness with others. Consider the following examples. Ai et al. (2003) collected information about religiousness, warrelated trauma, religious-spiritual coping, optimism, and hope from a sample of Muslims who escaped from Kosovo and Bosnia and settled in the United States. Testing a path model, they found that higher religiousness was positively associated with positive religious coping, which in turn was related to higher optimism. Aflakseir and Coleman (2009) examined the contribution of religious coping to the mental health of Iranian war veterans who took part in the Iran-Iraq war. Using a religious coping scale that was developed for use with Iranian population on the basis of Pargament et al. s (2000) scale, they found that positive religious coping was positively associated with general mental health status and negatively tied to PTSD symptoms. Khan and Watson (2006) asked Pakistani Muslim university students to recall a major difficulty they dealt with in their lives and to indicate whether they used various religiously related cultural practices to cope with potential associated symptoms (e.g., depression, anxiety). Based on their participants responses, they developed an 8-item Pakistani Religious Coping Practices Scale. This scale, which includes items such as Gave Sadaquah (alms) in the name of Allah and Read special daus (supplications) for the solution of the problem, was linked to higher levels of religious motivation and interest, and lower levels of depression. Abu Raiya et al. (2008) found that greater levels of Islamic Positive Religious Coping were consistently and strongly tied to greater levels of positive well-being indices (General Islamic Well-being, Purpose in Life, Satisfaction with Life) and lower levels of negative well-being indices (Physical Health, Alcohol Use). These findings are similar to those obtained from Christian (e.g., see Ano & Vasconcelles, 2005), Jewish (Rosmarin, Pargament, Krumrei, & Flannelly, 2009) and Hindu (Tarakeshwar, Pargament, & Mahoney, 2003) samples. Table 1 presents items from the PMIR that can be used to assess this important dimension among Muslim individuals. A number of interviewee quotes (Abu Raiya, 2005) illustrate some of the different methods that Muslims use to cope constructively with major crises in life. One participant said: I suffered a lot in my life because I lost my mom when I was 4 year-old. I was very frustrated because of that. This state of frustration has been relieved dramatically since I began truly adhering to Islam. Since then I have accepted the notion that this is my destiny and Allah s will. Another stated: My husband died a few months ago. If I did not believe that this is my predestination, I would be traumatized and it would take me years to overcome this event. But because I believe that this is Allah s wish and my husband passed to a better life, I felt calm from the first moment. And another interviewee said: Right now, I have family issues; at times I can become very down. Then I close my eyes and open the Qura n, and wherever I fall, that is what I read. You know, it is funny, but most of the time it will be the answer for me. Therapists can encourage their clients to identify and draw on their religious coping resources. The following case illustrates this point. A year ago, the first author met Omar for psychotherapy in a counseling center in a Midwestern town. Omar was a 21 year-old American Muslim male of Middle Eastern descent. He was brought to the counseling center by his employer who learned that

RELIGIOUSLY INTEGRATED PSYCHOTHERAPY WITH MUSLIMS 185 Table 1 Items Adopted From the Psychological Measure of Islamic Religiousness (PMIR) That Can Be Used To Assess Islamic Positive Religious Coping and Religious Struggle (Abu Raiya et al., 2008) Positive religious coping 1 Religious struggle 2 When I face a problem in life: 1. I look for a stronger connection with Allah 1. I find myself doubting the existence of Allah 2. I consider that a test from Allah to deepen my belief 2. I find some aspects of Islam to be unfair 3. I seek Allah s love and care 3. I find myself doubting the existence of afterlife 4. I read the Holy Qura n to find consolation 4. I think that Islam does not fit the modern time 5. I ask for Allah s forgiveness 5. I doubt that the Holy Qura n is the exact words of Allah 6. I remind myself that Allah commanded me to be patient 6. I feel that Islam makes people intolerant 7. I do what I can and put the rest in Allah s hands 1 All items have the same following response options: a. I do not do this at all (1); b. I do this a little (2); c. I do this a medium amount (3); d. I do this a lot (4). 2 All items have the same following response options: a. never (0); b. rarely (1); c. sometimes (2); d. often (3); e. very often (4). The numerical value in parenthesis indicates the score associated with each response option. Higher scores reflect more of the construct. Omar was not going to classes, was wandering aimlessly around campus, disoriented to time and place. Omar cast his life in religious terms. Only the story of Job can match my own, Omar sadly started his first therapy session, referring to the Biblical and Qura nic figure. H.A.R. soon learned that Omar s father, who was absent throughout all Omar s childhood, was undergoing a series of treatments for an incurable disease (and in fact, he would pass away towards the end of Omar s work with H.A.R.). H.A.R. also learned that Omar s mother was suffering from a complicated illness. In addition, his grandfather, who was for him a father figure, died a few months ago and Omar could not attend his funeral. Omar also recounted how his first love was killed in a car accident on the night of his 15th birthday. On top of that, he had recently broken his shoulder and had not sought medical treatment for a while because he did not have health insurance. Clearly, Omar had had more than his fair share of traumas. When H.A.R. asked Omar, so, what kept you going, Omar did not hesitate before responding, my belief in Allah, the Qura n and the story of Job! Because of his deep wish of not offending Allah, he said, he never intended to put an end to his life despite having frequent suicidal thoughts. The Qura n gave him a deep sense of consolation in the darkest times. And the story of Job who suffered immensely prevented my hope from dying. The Job metaphor played a central role in H.A.R. s work with Omar who improved significantly in the short course of treatment. To summarize, Muslims can draw on multiple Islamic teachings, beliefs and practices to cope with major life stressors. Mental health professionals should pay close attention to these invaluable tools while working with Muslim clients. Islamic Religious Struggles Can Be Detrimental: Address Them, Normalize Them! If Islam can be a source of support, strength, and comfort, it can also be a source of strain and religious struggles. Religious struggles are expressions of conflict, question and doubt regarding matters of faith, God and religious relationships (McConnell, Pargament, Ellison, & Flannelly, 2006; p. 1470). Researchers have identified three types of religious struggles: divine, intrapsychic, and interpersonal (Pargament, 2007). Divine struggles refer to tension in the individual s relationship with the divine. This tension might be manifested in questions about the benevolence and power of God, feelings of divine abandonment and anger toward God. Intrapsychic religious struggles are characterized by questions and doubts about religious beliefs and issues, such as the belief in the afterlife, and conflicts between religious teachings and human impulses and appetites. Interpersonal religious struggles include religiously-related conflicts with family, friends, and institutions. Like other religions (Pargament, 1997), Islam can be tied to struggle and negative religious coping. Some forms of religiousness have been associated with poorer outcomes among Christian samples. For example, negative religious coping methods (e.g., punishing God reappraisal, questioning God s power) and religious struggle have been associated with negative outcomes, such as poorer physical health and emotional distress (e.g., Pargament et al., 2000; Sherman, Simonton, Latif, Spohn, & Tricot, 2005). Abu Raiya et al. (2008) found that among Muslims, greater levels of Islamic Religious Struggle were linked consistently and strongly with greater levels of negative outcomes (Angry Feeling, Alcohol Use, Depressed Mood) and lower levels of positive outcomes (Positive Relations with Others, Purpose in Life). Other researchers (e.g., Aflakseir & Coleman, 2009; Khan & Watson, 2006) have reported similar results. A few quotes from interviews with Muslims (Abu Raiya, 2005) illustrate the concept of religious struggles and their impact on the psychological well-being of Muslims. One person said: Sometimes I feel that there are unjust things in Islam. Sometimes I also wonder if Allah, the Magnificent and the Almighty, will look at such a small and marginal creature like me; He may forget me. When I have these doubts and questions I feel tired, worried and tense. Another remarked: Music is another problem that I have with my religion. I listen to music but I am conflicted about it because a lot of ulma (Muslim scholars) say that it is haram (forbidden). I like music and believe that music is part of our culture expression... I do not know how music can be taken out from my life. Another stated: I never doubt Allah s existence, but I asked myself a lot if this is the way that Allah wants people to live. Why there are poor people? Why do people suffer? Why there are wars? Still another Muslim remarked: In Islam, the man is supposed to take responsibility for all the expenses of the household. Living in America is very difficult. Though I work hard, I cannot do that alone. When my wife says no, you need to

186 ABU RAIYA AND PARGAMENT do it, I want to use my money for my own sake that affects me negatively because religiously speaking I feel that she has a point. I feel that my religion victimizes me at times. Why is religious struggle among Muslims tied so robustly to negative outcomes? One possible answer is the fact that religious struggles address such fundamentally important matters and might pose a threat to the individual s core values, world-view and sense of significance. Another possible answer may have to do with the degree to which religious struggle is socially acceptable among Muslims. Expressions of religious struggles, especially doubts about the existence of Allah or the afterlife, may be particularly socially unacceptable in the Islamic culture given the potential lack of models of individuals who acknowledge and work through their religious struggles. As a result, Muslims who experience religious struggles may be especially vulnerable to stigma and loneliness, which may lead to depression and anger, and at times to alcohol or drug use. It is important to recognize that these explanations are speculative in nature. Future studies that specifically explore the phenomenon of religious struggle among Muslims might shed more light on the mechanisms that mediate between Islamic Religious Struggle and negative outcomes (Pargament & Abu Raiya, 2007). Because religious struggles are so robustly tied to mental and physical health, it would be inappropriate to overlook them in psychotherapy. How can mental health professionals address potentially problematic methods of religious coping in their work with Muslim clients? First, we recommend thoroughly assessing for the presence of Islamic Religious Struggle. Table 1 presents items from the PMIR that can assist clinicians in this regard. Second, it is important to avoid passing judgment on clients who are struggling by suggesting that their struggles are signs of a weak faith or religious immaturity. Rather, we recommend supporting clients by normalizing these processes. Returning to Hadia, the client who was surprised when asked about her religious life. She talked about struggling intensely with her wish to maintain her Islamic beliefs and practices while living in an open secular city where a lot of temptations are present for a girl in my age. She reportedly experienced a great deal of relief when H.A.R. commented: your struggle is really understandable... almost every person experiences personal struggles or concerns about aspects of his/her religion. In the process of normalizing religious struggles, it might be helpful to refer to individuals from the Islamic tradition (e.g., Muhammad, Moses, Abraham) or other traditions (e.g., Mother Teresa) as models of esteemed figures who experienced such struggles. Consider, for example, the following passage from the Qura n in which Abraham expresses doubt regarding the Divine s abilities. [My Lord! Show me how Thou givest life to the dead. He said: Dost thou not then believe? He said: Yea! Yea, but (I ask) in order that my heart may be at ease (The Qura n, 2: 260). Or clients could be reminded of the prophet Muhammad who struggled immensely in trying to spread the message of Islam and at times would have doubts about the successful completion of his mission. Directing the attention of Muslim clients who deal with religious doubts and struggles to the fact that even Abraham (who is known in Islam as the First Muslim and the Friend of God ), Moses (who, according to the Qura n, spoke directly to God) and Muhammad (who, according to Islamic teachings, was the final prophet to humankind), experienced such struggles could help normalize these struggles and offer hope that they can lead to growth and transformation. Finally, if the therapist lacks knowledge regarding the religious tradition of his/her client or feels uncomfortable normalizing religious struggles, a referral to a Muslim pastoral counselor or religious leader would seem appropriate to help clients work their struggles through before they become chronic. Stigma Associated With Mental Health Issues Is Widespread Among Muslims: Reach Out to Them! Many Muslims approach Western psychology with doubts, antipathy, and suspicion. For them, psychology is a Western, secular, antireligious endeavor and, therefore, is not tailored to the Islamic way of life (Abu Raiya et al., 2007). Further, research has shown that stigma associated with mental health issues is widespread in the Islamic world; many Muslims still react negatively to topics in the mental health domain such as psychopathology and psychotherapy (Al-Issa, 2000; Abu Raiya et al., 2007; Al Krenawi & Graham, 2000; Amer, Hovey, Fox, & Rezcallah, 2008). To bridge the gap between Muslims and psychology, mental health professionals should reach out to Muslims in general, and to Muslim religious leaders in particular. This can be achieved through workshops, presentations, and dissemination of written materials in settings that are most familiar and comfortable to Muslims, such as mosques and Islamic centers. Increased contact, collaboration, and respectful partnerships could reduce suspicion among Muslims towards the field of psychology. Further, we believe that the best antidote for stigma is education. Psychoeducation can happen inside and outside the therapy office. Mental health professionals can play a vital role in educating the Islamic public and potential and actual psychotherapy clients about mental health issues. In this process, psychotherapy should be demystified. Further, psychologists and mental health professionals interested in working with Muslim populations should try to overcome the secular bias inherent in Western psychology (Abu Raiya et al., 2007) by developing greater awareness of these biases, willingness to understand the religious mind frame of their clients, and openness to learning about Islam from their clients. Recently, H.A.R. was invited to facilitate a workshop pertaining to relationship issues that a Muslim Student Association held on a college campus. This workshop was well-attended and most participants seemed open to discussions of relationship difficulties and psychotherapeutic ideas. After the workshop, some participants contacted H.A.R. to help them find a psychotherapist in the community, or scheduled a counseling meeting at the local college counseling service. Later, H.A.R. was told that his presentation made them feel that psychotherapy is not against Islam and might be of benefit to them. Concluding Remarks In this paper, we attempted to translate empirical findings from a program of research that produced a PMIR into practical clinical applications. Our core findings and recommendations can be summarized as follows. First, Islam is deeply entrenched in Muslims lives and it seems to affect their well-being at multiple levels. Therefore, mental health professionals should inquire directly about the place of

RELIGIOUSLY INTEGRATED PSYCHOTHERAPY WITH MUSLIMS 187 religion in the lives of their Muslim clients from the early stages of counseling. Second, Islam is a multidimensional religion that can be understood and practiced by different people differently; some people might adhere to some of its elements but not to others. Consequently, clinicians must avoid simplistic views, stereotypes or overgeneralizations about Islam. Rather they should ask about what Islam means to their clients and educate themselves about basic Islamic tenets, practices and beliefs. Third, we encourage mental health professionals to help their Muslim clients draw on Islamic positive religious coping methods (e.g., seeking Allah s care and forgiveness, considering the stressor as a test from Allah, reading the Qura n to find consolation) to deal with stressors. Fourth, we recommend that clinicians assess for religious doubts and struggles, normalize them, help clients find satisfying solutions to these struggles and, if appropriate, refer clients who struggle to a Muslim pastoral counselor or a religious leader. Finally, in order to overcome stigma associated with mental health issues and the negative views that Muslims hold about western psychology in general, we recommend that mental health professionals reach out to Muslim populations and educate the Islamic public about psychology, psychopathology and psychotherapy. There is a dearth of research in this area. Additional studies are sorely needed to test the efficacy of these practical recommendations. Furthermore, it is important to consider the implications of gender differences (Ali et al., 2004) and fundamentalist versus more open-reflective religious attitudes (Dover, Miner, & Dowson, 2007) for psychotherapy with Muslim clients. 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