I Am Your Psychiatrist, Not Your Sheikh

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Let’s face it, being a Muslim mental health professional isn’t always easy. We often times deal with stigma from all around – from within the community, from society and from in the masjid. We may share a common desire to provide care, healing and hope to the mentally ill members  of our very own Muslim communities. Some of us are often driven by rescue fantasies — but when do such subconscious drives blur boundaries? While we embark on this professional path with optimism, bright eyes and a sense of idealism, as we start to see patients of similar backgrounds, we may experience  unexpected feelings and challenges. This can raise our anxiety about caring for Muslim clients and patients, especially for early career psychologists, therapists and psychiatrists. And so it is ironic that the very reason we ventured into this field can become an area of anxiety and consternation. And while Muslim  clients oftentimes prefer practitioners of similar backgrounds, we know Muslims are not a monolith and represent a wide range of ethnicities, races and degrees of acculturation. How do we deal with situations when we are not the perfect fit as our clients desire? Additionally, as providers, we need to have an understanding of our own identity when interacting with our patients, “…so that they can achieve effective cross cultural psychotherapy,” (Peteet, 2016).

“Some of us are often driven by rescue fantasies — but when do such subconscious drives blur boundaries?”

I remember one of my first encounters with a Muslim patient during residency training. A college student presented to the clinic with depression, severe anxiety and suicidal thoughts. Her parents recently discovered she was in a sexual relationship, and, thereafter, she expressed suicidal ideation. When it came time to directly speak to her, this young woman avoided all eye contact and kept her head down almost the entire time we were meeting. She ultimately expressed her sense of shame and worry that I would judge her. Suddenly, we were at an impasse, and I felt heartbroken that I could not help this young girl. At that moment, I realized the unspoken challenges when Muslims treat Muslims. The irony became apparent that while I wanted to help my community, the response would not always be smooth or reciprocal.

Such experiences have prompted me to think about underlying issues that do come up not only when we treat Muslim patients, but when we even advise members informally. Although we have a sense of idealism in providing mental health care in our community, it is prudent we recognize the challenges in treating Muslim clients and process such challenges if we wish to benefit the very brothers and sisters we seek to heal.

Transference and Countertransference in a Cultural Context

We are fortunate that our field recognizes the feelings that are stirred in each and every interaction in which we engage. Transference and countertransference are powerful concepts that have been long defined in our profession and are, “natural projective behaviors… expected in the counseling relationship.” As a reminder to us all, transference refers to, “certain unconsciously redirected feelings, fears, or emotions from a client towards the therapist that actually stems from past feelings and interactions… and is transferred into the current counseling relationship.” Glen Gabbard describes, “Every relationship in the clinical setting is a mixture of a real relationship and transference phenomenon,” (Gabbard, 2005). On the other hand, countertransference is the projection of the therapist’s experiences, values and repressed emotions that are, “…awakened by identification with the client’s experiences, feelings and situation that affect the dynamics of the counseling relationship.” As Gabbard further postulates, countertransference in the provider and transference in the patient are essentially identical processes – that each unconsciously experiences the other as someone from the past. Interestingly, countertransference is often conceptualized as the emergence of unresolved conflicts from the analyst’s unconscious. Therefore, transference and countertransference occurs in any healing dyad, and Muslims treating Muslims are certainly no exception.

Table 1. Common intraethnic, when therapist and client share ethnicity, transference and counter-transference. Adapted from Comez-Diaz.

Intraethnic
Transference
Definition Example
omniscient-omnipotent idealization of therapist Since Dr. Ahmad is a Muslim
she understands me 100%.
the traitor vilification of therapist
perhaps due to envy
Dr. Ahmed is a sell-out Muslim.
She wants to Americanize Islam.
auto-racist client’s strong negative feelings toward themselves are projected
to the entire culture
I won’t go to a Muslim psychiatrist. They are so judgmental. They are not going to get my problems.
ambivalence unresolved issues of the client’s cultural identity plays out in the therapeutic encounter Eight weeks into therapy, the client begins to pray and read the Quran more. She feels somewhat proud and more connected spiritually. But she also accuses the therapist for manipulating her to be more religious.

 

Intraethnic
Contertransference
Definition Example
overidentification sharing a similar ethnic/cultural background results in therapist overidentifying with client Dr. Ahmed may not ask about substance use/alcohol use, assuming patient’s level of religiosity is similar to her own.
us and them therapist unconsciously colludes with client, creating a we as “victims” versus “the system” dynamic Dr. Gomez understands clients feelings of being discriminated against and may give tacit permission to ‘beat the system’ via illegal activities.
distancing to prevent overidentification therapist creates boundaries Dr. Khan becomes aware of how much she identifies with patient and may neglect to explore key areas for fear of bringing up her own negative feelings.
tribal responsibility therapist feels responsibility to better the condition of the client Dr. Ahmed has a full caseload but accepts client, feels responsible to help, “one of our own.”
cultural myopia therapist unable to notice patterns or formulate case appropriately because the therapist attributes issue to culture Dr. Ahmed is not sure if client is in an emotionally abusive relationship or if dynamics are acceptable culturally.

 

As providers, we also come with our individual worldviews, influenced by our own upbringings, level of acculturation and how closely we may adhere to religious teachings and/or spirituality. Working in an intraethnic dyad can intensify our own feelings about culture and religion while also generating a sense of ambivalence, as we overlook the impact of our own cultural baggage. Additionally, we must consider that most of us are trained within a Euro-centric or secular framework. Integration of religion is seldom done in training. While Muslim providers have a basic cultural understanding of religious tenets and norms, we must recognize our own limitations: that we tend to offer treatment within the orientation in which we trained. Thus, we may unintentionally dismiss cultural and religious values of our Muslim clients (Keshvarzi & Haque, 2013). We must acknowledge that Muslim psychologists and psychiatrists simply may not know how to effectively marry treatment in a religio-cultural model.

What follows is a brief description of the types of transference and countertransference we may encounter in caring for Muslim patients. Although Muslims vary in ethnicity, acculturation, race and level of religiosity, we will keep this discussion general.

Transference Reactions

Traditional models of psychotherapy tells us to avoid seeing patients or clients that we know in order to maintain healthy boundaries with our patients and clients; however, sometimes community members specifically seek familiar faces to provide care. They do not realize the potential challenges that can surface, or the common etiquette that has been established by our field. Several issues can come up when treating community members. For example, some acquaintances may limit disclosure in an effort toward self-preservation, particularly on sensitive topics. Muslim providers, in turn, may be hesitant to delve into more sensitive details and conflicts, thus stifling therapy and falling short of expected or ideal outcomes.

I recall another young adult I saw as a resident, just a few years younger than me. I had great difficulty obtaining any details about her presentation and her responses to my questions were vague and nebulous. She seemed to assume that I must inherently know her experience thoroughly, being of a similar ethnic background, and, also being a visible Muslim wearing hijab. Looking back, I can now identify that this patient may have been experiencing a type of transference because of our similar backgrounds. And, in fact, this type of psychodynamic response has been described where the therapist is viewed as omniscient or omnipotent, and thus a complete idealization of the provider.

Sometimes such feelings can eventually result in a type of ambivalence as well, as the internalization and idealization of the provider can be somewhat provocative if clients fear too much psychological closeness. This can bring forth some unresolved issues about the patient’s own ethnocultural background (Comas-Diaz 1991). This may be particularly relevant for Muslim adolescents, who already have the development task of exploring and consolidating their identity in this era of Islamophobia. Muslim youth in particular must cope with experiences of bicultural identities, racial and ethnic discrimination and oppression, and have additional complex layers to age old questions (“Where are you from?” and, “Who am I?”).

And so, the client can feel a dichotomy of closeness yet a need for distance. “This mix of feelings may lead to a subtle but rather profound ambivalence that can be easily be missed or may be confusing to the unsuspecting therapist,” (Comas-Diaz, 1991). Treatment may be cut short due to this ambivalence if not adequately acknowledged or processed openly.

Intraethnic Countertransference Reactions

From a countertransference perspective, in an intraethnic dyad, over-identification on the part of the provider is another documented type of reaction. This can manifest in a few different ways, the first of which has been described as an us and them mentality. This reaction can be prevalent in groups facing some type of oppression or discrimination and thus lower societal status, as is the case of many ethnic minorities. The provider may over-identify with patients in terms of their shared victimization and, most significantly, may attribute all the patient’s problems, complaints and conflicts to their ethnic identity. Therapy can then turn into a shared fortress against perceived common threats (Comas-Diaz, 1991).

Additionally, to prevent this over-identification and fear of closeness, the provider may also distance himself or herself from the patient, another type of ambivalence. Other times, a similar cultural context can lead to cultural myopia, or the inability to see or interpret all issues clearly. All issues are seen only in a cultural context and may risk being normalized. Or all other issues besides those related to being a minority might be ignored. The client might withhold information such as family conflict – in an effort to protect one’s family and privacy – and the therapist may allow this to happen as well, and thus allow the patient to control the therapy. Providers may experience ambivalence also if they overlook their own identities in a pursuit of universalist values. We also must recognize that as we are schooled in more traditional methodologies of healing, we may have difficulty integrating faith-based and cultural factors in treatment and, again, ambivalence can ensue (Comas-Diaz, 1991).

After a culmination of unique and sometimes challenging interactions with Muslim patients, we must recognize why some Muslim providers may hesitate to see clients and patients from the community, consciously or unconsciously. Discussing cases with supervisors or mentors may help to uncover some of these reactions at play. Most importantly, being able to process these reactions with our patients and clients will help us to adequately address them and move on to build stronger therapeutic alliances. Although this discussion was brief, there are many other questions we can ask. What are the dynamics of Muslims with differing levels of acculturation? Of varying racial or ethnic backgrounds? What are the unique dynamics that child psychiatrists and therapists encounter when interacting with parents and children? What are ethical issues that can arise? Further discussion is needed to explore these rich dynamics. Asking the questions and being thoughtful in our interactions are just the first steps to successful interactions and thus positive outcomes with our Muslim population — the very people we hoped to heal when embarking on this path.

Comas-Diaz, L. and Jacobsen, F. Ethnocultural transference and countertransference in the therapeutic dyad. American Journal of Orthopsychiatry 61(3), 1991.

Gabbard, Glen. Psychodynamic Psychiatry in Clinical Practice. Washington DC, American Psychiatric Publishing, Inc, 2005.

Keshavarzi, H., & Haque, A. (2013). Muslim mental health within an Islamic context. The International Journal for the Psychology of Religion, 23, 230-249.

Peteet, J. Does a therapist’s worldview matter? Journal of Religion and Health  55:1097-1106, (2016).

Dr. Saba Maroof is a board certified Child, Adolescent and Adult Psychiatrist working in various outpatient settings in the Metro Detroit Area.  She lectures medical students and residents on a wide variety of topics such as acculturation, treating Muslim patients and the role of religion and spirituality in mental health. She recently started a podcast called, “Unsung Heroes: Stories to Inspire.”

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