The Efficacy of Religious and Muslim Based Cognitive Behavioural Therapy
By: Hamid Waqar
Due to the large numbers of religious people in the world and the effectiveness of cognitive based therapies in areas such as depression and anxiety, it would be advantageous to research the efficacy of religious based cognitive therapies. The cultural compatibility hypothesis, therapeutic alliance, refusal of conventional therapy amongst religious individuals, and religious ideology support an advantage of religious based therapy. Furthermore, Muslim patients have a stronger belief in the efficacy of these therapies over their conventional counterparts. Research has supported this theory finding advantages in the efficacy and speed of recovery of these therapies. But, these therapies have been critiqued conceptually and empirically. It has been claimed that the support of these therapies is diminished due to researcher allegiance and publication bias. Furthermore, Muslim based therapies are claimed to be at odds with Islamic ideology. Furthermore, the research is limited in scope and has not been replicated. These critiques succeed in diminishing support for religious and Muslim based therapies, but the field remains promising.
The Efficacy of Religious and Muslim Based Cognitive Behavioural Therapy
Research examining the efficacy religious-based therapy in general and Islamic-based therapy in specific compared to non-religious based cognitive behavioural therapies is becoming a popular trend (Hafizi, Tabatabaei, Memari, Saghazadeh, and Koenig, 2016). Defensible arguments on both sides of the issue exist. There are arguments supporting religious-based and Islamic-based therapies over their secular counterparts. There are also critiques which dismiss these findings. This essay will argue that integrating religion into therapy for religious minded individuals, especially practicing Muslims, is promising, but needs to be explored in greater detail.
The importance of this topic can be demonstrated by examining the sheer numbers of religious people in the world. The Pew Research Centre found that 84% of the world’s population describe themselves as being part of a religion (Hackett and Grim, 2012). Nearly one billion people of this large population identify themselves as Muslim, which is defined as a person who follows the religion of Islam (Esposito, 2005). Anderson et al. (2015) define being religious as “an allegiance to the beliefs, teachings or traditions of an organised religion, arising from a group of people with common beliefs and practises concerning the sacred.” This importance of researching religious based therapy is further intensified when it is demonstrated that there are higher percentages of religious individuals suffering from mental health issues than their non-religious counterparts. For instance, 80% of people with enduring mental health issues adopt religious methods of coping (Tepper, Rogers, Coleman,& Malony, 2001), and patients are interested in discussing religious concerns in therapy (Rose, Westerfeld, & Ansley, 2008).
It has been demonstrated that cognitive and behavioural based behavioural therapies, such as CBT, have been effective in treating various psychological illnesses, such as schizophrenia (Dixon et al., 2010), depression, regardless of the therapy being delivered face-to-face or via internet (Anderson, Topooco, Havik, and Nordgreen, 2016), anxiety, regardless of therapy being delivered face-to-face or via internet (Podina, Mogoase, David, Szentagotai, and Dobrean, 2016; Reger and Gahm, 2009), post traumatic stress disorder (Kowalik et al., 2011), and obsessive compulsive disorder (Ost, Havnen, Hansen, and Kvale, 2015). Religious CBT mirrors conventional CBT treatments while adding religious content and motivation to the process (Koenig, 2012).
It is expected that religious CBT would be advantageous for religious populations due to the cultural compatibility hypothesis, therapeutic alliance, refusal of therapy, and religious ideology. The cultural compatibility hypothesis asserts that similarities between the client’s culture and therapy lead to desired therapeutic outcomes (Fraser, et al, 2009; Thorpe, 1991). This would support an advantage of religious CBT over conventional CBT. It has also been found that therapeutic alliance is developed quicker with religious CBT than conventional CBT (Koenig et al., 2016). Furthermore, it has been found that many depressed religious individuals refuse non-religious therapy or feel guilty about their depression and refrain from seeking aid (Koenig, 2012). It has also been suggested that certain religious underpinnings increase the effectiveness of CBT, such as a sense of meaning of life (Gerwood, 2005), encouraging social support (Scott, 2003), and submitting oneself to a higher power (Cole, 2000).
Therefore, it is not surprising that research has supported an advantage of religious cognitive based therapies over conventional cognitive based therapies in effectiveness and speed. For instance, a meta-analysis found moderately strong evidence supporting religious therapies over conventional therapies (Smith, Bartz, and Richards, 2007). Religious CBT has been found to be advantageous over conventional CBT in religious individuals (Azhar and Varma, 1995, Propst, Ostrom, Watkins, Dean, and Mashburn, 1992, Worthington, Hook, Davis, and McDaniel, 2011). Furthermore, Anderson et. al. (2015) examined seven religious CBT programs and found that the religious based therapies were beneficial in the treatment of depression, but the benefit fell just short of statistical significance. Religious CBT has also been shown to produce effects quicker than conventional CBT (Azhar, Varma, and Dharap, 1994, Prospt, 1980, Prospt et al., 1992, Rosmarin, Pargament, Pirutinsky, and Mahoney, 2010). This is important because it is advantageous for a patient to recover from their mental illness quicker.
These results apply more to the Muslim community than other religious groups because Muslims, have a stronger belief in the efficacy of religious coping methods which leads them to select these methods more than followers of other religions (Loewenthal, Cinnirella, Evdoka, and Murphy, 2001). Research has supported this by displaying an advantage of cognitive therapies tailored for Muslim patients over conventional therapies (Anderson et. al., 2015). Furthermore, patients have recovered quicker from depression in Muslim patients receiving cognitive therapies developed for Muslims than those being administered conventional therapies (Azhar and Varma, 1994; Hook et al., 2010; Razali, Hasanah, Aminah, and Subramaniam, 1998).
These studies assert the efficacy of religious and Muslim tailored cognitive based therapies over their conventional counterparts, but there are a number of conceptual and empirical critiques which must be considered. Valid critiques regarding the validity of these studies, such as researcher allegiance (Anderson, et. al., 2015) and publication bias (Worthington, et. al., 2011), diminish the strength of the previous findings. Researcher or experimenter allegiance is an influential bias which is referred to as the confidence that the researcher has about the superiority of his intervention (Dragioti, Dimoliatis, Fountoulakis, and Evangelou, 2015; Munder, Brutsch, Leonhart, Gerger, and Barth, 2013). Publication bias refers to the publication of studies which confirm the research hypothesis and discarding of studies which refute the research hypothesis. According to publication bias, studies which support religious and Muslim therapies would be published whereas studies which fail to support these therapies would be discarded. Furthermore, the lack of manuals and variety of implementation of religious and Muslim therapies has been pointed to as a major problem with this research field (Lim, Sim, Renjan, Sam, and Quah, 2014). These critiques are valid and diminish the support of religious and Muslim based therapies, but do not constitute a complete dismissal of the research in this area.
Empirical and methodological critiques of the research in this field further diminishes the support of religious and Muslim based therapy. One major critique is that the studies which asserted statistical significance have not been replicated (Hook et. al., 2010). This critique does not denote the invalidity of previous research, rather it suggests a need for future research to replicate such findings. Albeit, until sufficient replication is achieved the support for religious and Muslim based therapies will be considered empirically inadequate.
Lim et. al. (2014) list a number of methodological critiques of studies supporting religious and Muslim based therapies. Examples of these methodological critiques are issues regarding the comparator and concentration on bivariate relations without controlling for demographics. Many studies compared religious or Muslim based therapies to unconventional non-CBT treatment or medication (Azhar and Varma, 1995; Azhar, Varma, and Dhaharp, 1994; Razali et. al., 1998). Although this is a valid critique for some of the studies, it does to apply to all of the studies supporting religious and Muslim based therapies, such as an experiment conducted by Ebrahimi, Neshatdoost, Mousavi, Asadollahi, and Nasiri (2013) which compares a spiritually integrated psychotherapy and conventiaonl CBT with for Muslims diagnosed with depressive symptoms. Thus, this critique diminishes the number of studies supporting these therapies, but does not put the entire field into question. Furthermore, Lim et. al. (2014) critique these studies by stating that they merely concentrate on the bivariate relations without controlling for demographic information. This is a problem because it may lead to outliers which taint the study results causing improper conclusions. After mentioning this and the remaining methodological critiques, Lim et. al. (2014) admit that “religious modified CBT can at best be considered a probably efficacious treatment for depressive disorders and generalised anxiety disorders.” (p.9) Hence, these critiques hinder the support that these studies found, but do not remove the promising nature of religious and Muslim based therapy.
In addition to these critiques, there are some critiques that are specific to Muslim based cognitive therapies. Beshai, Clark, and Dobson (2013) claim that the religion of Islam is ideologically at odds with the CBT program and thus cannot be a considered as a logical substitute for religious Muslims. This study introduces a number of Islamic principles which are claimed to be incongruent with conventional CBT. For instance, one principle states that Islam considers the Quran to be the sole measure of reality which contradicts the CBT principle of the nonexistence of objective reality. This is a simplistic conclusion drawn from the Muslim belief that the Quran is the unaltered word of God, because the Quran itself encourages Muslims to contemplate over nature and the human being (Quran, 2:164 and 51:21). Thus, one can enter a tailored CBT program and utilise cognitive thought processes leading to behavioural change within the Islamic framework. Another Islamic principle that is mentioned states that one’s actions are not free, rather depend on metaphysical entities. This is another simplistic take on a heavily debated theological concept. An authoritative figure in Shia Islam, Imam Jafar bin Muhammad, is reported to have negated radical determinism and absolute freewill opting for a middle-ground. (Majlisi, 1982) This was an answer to a question about divine omnipotence and has been interpreted by influential Islamic scholars to mean that although one’s freewill is dependent upon God, it does not negate his ability to choose his course of action (Misbah-Yazdi, 2006). Thus, one can hold a belief in this principle and benefit from CBT. The final example of an Islamic principle that is claimed to be incongruent with CBT is that “the self is not separable from others,” (p.201) thus individual rights are disregarded. In this case, this belief is falsely attributed to Islam. Although social responsibility is heavily encouraged, individual responsibility remains an integral part of faith for a Muslim, as the Quran states: “Whoever strives…does so only for his own good.” (Quran, 29:6) Therefore, each individual is responsible for his own actions which is congruent with CBT. Hence, these ideological critiques do not constitute a rejection of religious based CBT programs for religious Muslims.
Muslim-based cognitive therapies are further critiqued on an empirical level. It has been found that there is insufficient evidence supporting Muslim-based cognitive therapies (Mir, et. al. 2015). Additionally, whatever evidence has been provided is considered to be substandard and the content of the Muslim-based therapies are rarely provided (Walpole, McMillian, House, Cottrell, and Mir, 2013). In opposition to publication bias, there is also one study which found religious CBT to be inferior to conventional CBT (Razali, Aminah, and Khan, 2002). But, Anderson et al. (2015) consider the reason for this finding to be the data subsets of religious and nonreligious Muslims. Thus, religious CBT was found to be more advantageous than conventional CBT in the religious subgroup, but not in the nonreligious subgroup. Similar to research about religious CBT therapies, these critiques diminish the support for Muslim-based cognitive therapies, but the field remains promising because further research can quell these critiques.
Another potential limitation is that there are many sects of Islam which hold differing beliefs on core issues. Many of these sects are not represented in research or cognitive based therapies. For instance, an informal literature review by the author found that a religious based cognitive therapy tailored for Shia Muslims is nonexistent. The cultural compatibility hypothesis would suggest the implementation of a therapy tailored for each sect (Fraser, et al, 2009; Thorpe, 1991). Thus, Haque (2004) suggests that the diversity within Muslim populations, both religious and cultural, must be considered in religious based therapies. This limitation would suggest that general Muslim based therapies would not be effective for all Muslims, rather tailored therapies for various sects should be devised.
Therefore, there have been a number of studies which claim to empirically support religious and Muslim based cognitive therapeutic interventions (Hook et al., 2010; Koenig, 2012; Smith, Bartz, and Richards, 2007; Worthington et al., 2011). However, these findings have been tarnished by ideological, methodological, and empirical criticisms. But, the ideological concerns were determined to be weak and the methodological and empirical critiques largely point to insufficient evidence, rather than contradictory evidence. These critiques can be overcome through the development of interventions which address the needs of the various sects and cultures within the Muslim population and placing them under the microscope of valid scientific evaluation free from research allegiance and publication bias. Until this happens, religious and Muslim based interventions will remain promising, but not scientifically validated.
Hamid Waqar is a third year psychology student at the University of Wollongong and has over 10 years experience in the Islamic Seminary of Qum.
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