I Am Your Sheikh, Not Your Psychiatrist

 

By: Refai Arefin, J.D.

 

“The Imam, both grounded in Islamic knowledge and in a position of public trust, is often the first person American Muslims think to call in times of crisis.”

 

There is an oft-repeated verse of the Qur’an that says, “Ask the people of knowledge if you don’t know.”  It encourages consultation of an expert in times of crisis. In Muslim America, it means that the Imam, both grounded in Islamic knowledge and in a position of public trust, is often the first person American Muslims think to call in times of crisis.  Far too often, it means that the late night callers – one reporting spousal abuse, a teenager with issues at school, and another seeking a listening ear – believe that the Imam holds an immediate solution to their problem. Far too often, the person some of these individuals truly need is a mental health professional.

 

One summer afternoon, I was in the middle of teaching a Quran Tafseer class when a couple and their three young children came rushing in.  The husband proceeded to explain, in front of his children, that in a fit of anger he had pronounced divorce three times. He asserted that all he needed was for me to say that it didn’t count because he wasn’t mentally aware of what he was saying.  Although they lived five minutes away, I had never met them and they had never been to the Masjid before. 

 

“Many Imams are not well informed about mental health issues.  Yet, in a study of 62 imams across the U.S., it was found that 95% reported spending significant time each week providing counseling to their congregants”

 

I knew from the husband’s sentence that I only had ten minutes before they disappeared back into the ether.  I advised them about the religious opinions and views about what had transpired, emphasized that the bigger issue was what would cause someone to take such an extreme step, and informed them of the resources that were available in the community.  Rather than confront the reality of his situation, he said, “You don’t look like the Imam” as I stood there in my blue jeans with a trimmed beard. Off they went, never to be seen again; no intake forms completed, no waivers signed, and certainly no payment rendered.  I was left wondering what had happened to them, and saddened that the support they envisioned receiving from the masjid was an expedient fatwa rather than the couples counseling they actually needed to fix the root of their conflict.

 

My efforts to help were clearly rebuffed because they viewed the Mosque as a place to seek religious rulings once things got out of hand, not a place for emotional support and access to resources. Many Imams are not well informed about mental health issues.  Yet, in a study of 62 imams across the U.S., it was found that 95% reported spending significant time each week providing counseling to their congregants (1). Another study conducted in 22 mosques across New York after the September 11 attacks found that imams could play a critical role in promoting mental health due to their trusted place in the community (2).  Like most other imams, I spend hours each week counseling community members.

 

“Mental health professionals may face their own professional limitations when it comes to the complexity of certain cultural and religious issues intertwined with a patient’s mental health.”

 

There is a growing movement among Muslim leaders for a more collaborative approach with mental health providers.  Mental health experts and Imams approach counseling with different professional lenses. Imams are well informed about the intergenerational trauma in the community and the intersectional nature of the problems faced by community members.  They are also well positioned to address the self-stigma that is common among Muslims who seek help for depression and other health conditions they view as abnormal. Further, Imams are usually more familiar with their congregation’s social and cultural context and because of their lack of training in the mental health field, they are more likely to view problems in terms of environmental factors rather than a physiological issues such as a shortage of serotonin receptors. If Imams and mental health providers learn more about each other’s approach, it will lead to better mental health outcomes.  For example, a couple of years ago, a teenager in the community was placed in a residential psychiatric facility because of his attempts to commit suicide. While the psychiatrists addressed the serious chemical imbalance, my involvement was helpful for the family as they navigated this difficult situation and the patient, who faced his loved ones’ judgment. Knowing my own limitations, I focused on giving the family and patient a sense of normalcy and hope.  

 

Similarly, mental health professionals may face their own professional limitations when it comes to the complexity of certain cultural and religious issues intertwined with a patient’s mental health. In another case, a female teenager attempted suicide after her parents arranged for her to marry her cousin when they discovered she had a boyfriend.  The hospital viewed her case as a psychiatric issue and the State viewed it as abuse since neither were able to connect with the family and address the environmental stressors. The mental health team needed the intervention of a trusted imam who could help provide context and further information to help the patient and family. After referring the case to my wife, a Family and Marriage Therapist, we were able to place her in the care of other family members.

 

“Not all Imams and scholars are open to working closely with mental health providers.”

 

In many Muslim countries, it is often repeated that Islam is a complete way of life and the phrase “Islam is the solution” is the mantra.  This leads some to shun doctors, thinking that choosing medicine over prophetic medicine shows a lack of piety or faith. The Imam, coming from a position of religious authority and social influence can help to remove that stigma by encouraging those in need to seek solutions with mental health professionals. Many Mosques have been trailblazers in this regard – All Dulles Area Muslim Society (ADAMS) and the Islamic Association of Raleigh come to mind, but there are others doing the same. Once I visited the home of a twelve-year-old girl whose family was convinced that she was possessed by a jinn because of her hallucinations and disorganized speech.  While she was showing what I regarded as signs of schizophrenia, I offered Ruqya (healing through the Qur’an) and emphasized the need for her to concurrently follow up on the referral from the school psychologist to treatment with a psychiatrist. When she started to get better, the family was convinced that the Ruqya had worked. I had to explain to them that Allah often heals through medicine before they finally understood that it is not necessarily a binary proposition. It was important to balance both the medical and spiritual approach to healing and give both views their due respect in the eyes of the patient and her family. 

 

Not all Imams and scholars are open to working closely with mental health providers.  The famous Saudi scholar Aidh Al-Qarni’s book, “Don’t Be Sad” has sold more than 2 million copies around the world.  Al-Qarni claims that idleness and sinning are the primary reasons for sadness, with religiosity as the antidote for low mood (2).  There are countless other examples of scholars who are dismissive in their public statements about depression, attributing it to dissatisfaction with Qadr, or God’s predestined outcomes. (3, 4).  There is also resistance to Western explanatory models or conceptualizations of mental illness. This stems from the perception that these models are primarily based on Freud’s ideas and are not grounded in “Islamic Psychology.”  However, when the Prophet (s) was asked whether the companions should seek medical treatment for illnesses, he replied, “Yes, you should seek medical treatment, because Allah, the Exalted, has let no disease exist without providing for its treatment, except for one ailment, namely, old age (5).”  While the traditional Islamic approach to low mood and sadness emphasizes mindfulness, thankfulness and charity, which fits nicely with cognitive behavioral therapy approaches for some cases, it also has the danger of not properly viewing depression as a medical condition with a genetic or biomedical causation.

 

“Mosques must invest in Imam positions and Imam training, especially if counseling is a considerable part of their jobs.”

 

There is reason to believe that having Imams at the front lines of mental health could be beneficial.  For this framework to yield good outcomes, we need three separate things to take place. First, Imams need to be skilled and trained at identifying mental health issues.  Second, Imams need to be able to have referral networks at their disposal so appropriate professionals can take over where needed. Third, Imams need to cultivate both best practices and collaborative practices so community members get a holistic treatment plan.  It is important to note that although these suggested steps may help build toward more collaborative mental health care for Muslims, Imams are only one part of a greater network of support for the community.  

 

It is apparent that Imams would greatly benefit from pastoral counseling training programs and certifications.  The typical Imam is in need of self-care himself, barely getting an hour off in many cases, so we can expect many Masjid boards to roll their eyes when asked to send their Imams for professional development.  It remains a rarity to find an Imam that has completed coursework in mental health or counseling, myself included. Due to this, Mosques should recognize the importance of keeping a professional and committed Imam in a sustainable manner.  They must invest in Imam positions and Imam training, especially if counseling is a considerable part of their jobs.

 

“Imams can serve as a trusted link to someone in a network, ultimately leading to better mental health outcomes. ” 

 

Although few imams have the qualifications, it is hard to deny that there is a population of American Muslims in need of mental health resources that are already reaching out to their local Imams.  A study of Muslim Americans found that 19% were willing to seek help from their religious leader, compared to only 11% from mental health professionals (6). Capturing these populations does not pose a significant obstacle.  Like most imams, I have counseled community members with sex addiction, alcohol abuse, porn addiction as well as trauma. I was often surprised at how easily many will share intimate details. One couple requested several sessions of couples counseling because they felt they couldn’t speak openly with anyone else.  If Imams are trained, they can help community members to identify the need to consult with a mental health provider. Imams can serve as a trusted link to someone in a network, ultimately leading to better mental health outcomes.  

 

The greatest challenge is the absence of a referral network for the Imam to utilize, which the Institute of Muslim Mental Health is working to address.  Imams rarely have a list of contact information for mental health professionals who can take on their medical cases with cultural competency. The obvious solution lies in institution building – centers for family services and for counseling.  This would alleviate the burden on Imam, alleviate some of the cultural stigma, and also normalize the idea of seeking professional mental health services.

 

A formal collaborative approach signals to the community that mental health matters – that resources are being devoted to support mental health and that seeking help should not be stigmatizing.  It also prevents the dependence of outcomes on who the Imam is at any particular time and how open he is to addressing mental health. Throughout world history, the mosque has always been more than simply a place for prayer.  In the West, this idea has spread somewhat slowly to include a learning, youth, and community center. The Mosque, idealized as a center for Muslim life, has the potential to soon become a place for the first steps of healing.