|Sufism and mental health
|S Haque Nizamie1, Mohammad Zia Ul Haq Katshu2, NA Uvais3
1 Department of Psychiatry, Central Institute of Psychiatry, Ranchi, India
2 School of Psychology, University of Wales, Bangor, United Kingdom
3 Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Delhi, India
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Date of Web Publication-Jan-2013
| Abstract Human experience in, health and disease, always has a spiritual dimension. pirituality is accepted as one of the defining determinants of health and it no more remains a sole preserve of religion and mysticism. In recent years, pirituality has been an area of research in neurosciences and both in the nderstanding of psychiatric morbidity and extending therapeutic interventions it seems to be full of promises. Sufism has been a prominent spiritual tradition in Islam deriving influences from major world religions, such as, Christianity and Hinduism and contributing substantially toward spiritual well‑being of a large number of people within and outside Muslim world. Though Sufism started in early days of Islam and had many prominent Sufis, it is in the medieval period it achieved great height culminating in many Sufi orders and their major proponents. The Sufism aims communion with God through spiritual realization; soul being the agency of this communion, and propounding the God to be not only the cause of all existence but the only real existence. It may provide a vital link to understand the source of religious experience and its impact on mental health.Keywords: Mental health, psychotherapy, SufismHow to cite this article:
Nizamie S H, Katshu MZ, Uvais N A. Sufism and mental health. Indian J Psychiatry 2013;55, Suppl S2:215-23
How to cite this URL:
Nizamie S H, Katshu MZ, Uvais N A. Sufism and mental health. Indian J Psychiatry [serial online] 2013 [cited 2019 Dec 8];55, Suppl S2:215-23. Available from: http://www.indianjpsychiatry.org/text.asp?2013/55/6/215/105535
Humans have always had the quest to know themselves, to know the world around them, and to know their place in the world. The history of mankind is replete with people who like Mitya in The Brothers Karamazov are “haunted by a great unsolved doubt.”  This quest has led man from the dogmas of religion to the discourses of philosophy and finally to the empirical sciences. Though we have made some progress in understanding ourselves vis-à-vis the nature, the answers still remain elusive. Spirituality, whether associated with particular religions or otherwise, has been practiced since ages and claims to offer answers to the “unsolved doubts.” The recent years have witnessed a surge of interest in spirituality and the advancements in neurosciences offer an opportunity to understand it from a more scientific standpoint and put it in proper perspective. Across cultures, spirituality forms an important part of belief systems of majority of the people. It affects the mental well-being and the understanding of mental illnesses in terms of the etiology, meaning and the modalities of redressal. It seems important that mental health professionals should be aware of the ways spirituality affects the mental well-being of individuals in both health and disease states. This paper will outline the basic foundations of Sufism – a particular kind of Islamic mysticism, how it affects the mental well-being of individuals associated with it, and its interface with clinical psychiatry in terms of implications for diagnosis and management.
The need to know Sufism
Human cognitions and behaviors are determined largely by a set of facts and values. The facts are mostly derived from the science and the values have their origin in religious or non-religious philosophies such as humanism and existentialism.  Spirituality being an integral part of most of the religious philosophies provides the value system for the majority of people and thereby influences their well-being. Recognizing this, the spiritual well-being, in accordance with the social and cultural patterns, was accepted as one of the important determinants of health by the World Health Organization during the 37 th World Health Assembly in 1984.  Spiritual teaching has already found its place in the curriculum of many medical schools in the Western world. , From a mental health perspective, spirituality seems to have a far greater role as these operate on the same ground – the brain or as some would like it call it the mind or the soul. In fact, there are studies that show positive as well as the negative impact of the spiritual and religious beliefs and practices on the physical and mental well-being of people who subscribe to spiritual or religious practices. ,,,,, Sufism, having a large following both in the Muslim world and outside coupled with migration of large numbers of people from eastern Sufi oriented lands to the west, is a rapidly growing form of spirituality that needs to be understood in terms of its impact on the mental well-being of its followers and the potential interactions in the mental health care clinical settings.
From a more philosophical point of view, Sufism provides an opportunity to understand the source of religious knowledge in general and Islamic knowledge (revelation) in particular. In Sufi traditions, it is believed that Sufis can have similar knowledge revealing experiences as are the source of religious knowledge in the form of revelation of the Quran (the scripture of Islam) to Muhammad (the Prophet of Islam). The study of these Sufi experiences which share phenomenological ground with the prophetic experiences of revelation provides a possibility for the scientific study of the sources of religious knowledge. , From day-to-day clinical practice to research, the study of the normal and abnormal perceptual/experiential phenomena and its implications form an integral part of the mental-health related sciences and puts the students of mental-health sciences in a coveted position to study the Sufi experiences.
Historical background of Sufism
The term Mysticism had its beginning in the mystery cults of the Greeks, which involved a close circle of devotees who because of their innate capacity were believed to have the knowledge of the divine revealed to them. Etymology aside, mysticism has been practiced since ages across all the cultures and has been a vital part of the major religions of the world. Perhaps it represents an innate desire of the man to understand himself and the world around. All forms of mysticism aspire for a union with the divine and believe that it is only possible through the purification of soul to receive direct knowledge and revelation from the divine.  Islam began in 610 AD and established itself through the teachings of Muhammad believed to be revealed to him by God through the archangel Gabriel primarily among the Arab pagan and Christian communities. The close contact between the Muslim and the Christian communities during the formative years of Islam had its influence on the development of the Sufism – the mystic traditions of Islam. Sufism established itself within the traditions of the Islam as laid down in the Quran believed to be revealed to Muhammad by God. The Sufis believe that communion with God is possible through Muhammad, who was the recipient of the knowledge of the heart (Ilm-e-Sina) besides the outer knowledge (Ilm-e-safina). Ali, one of the Muhammad’s companions and son-in-law, is considered to be the first Sufi to whom the Ilm-e-Sina was revealed by Muhammad to be taught to those capable of understanding it. Contrary to the mainstream, some schools of thought in Islam denounce Sufism as heretical and consider it an innovation in Islam. , However, the concept of God, the possibility of esoteric knowledge and the ways to access God through purification of self by means of prayer, fasting and repentance that form the foundations of Sufism find their source in the Quran and the teachings of the prophet known as Hadith. 
Sufism in the beginning was primarily an individual endeavor. The Sufis would usually live in isolation practicing self-mortification and were distinguished by a cloak of wool (Suf), a tradition of Muhammad, which is believed to be the origin of the word Sufi. , A group of such devouts lived a life of poverty and incessant prayer and fasting on a stone bench in front of Muhammad’s mosque. These people of the bench (Ashab-e-suffa), 45 to over 300 in number, were given to much weeping and repentance and are believed to be the origin of the Sufism.  However, the name Sufi was given to such ascetics only around the second century of death of Muhammad. The Sufis in the early period were primarily ascetics and Sufism had not yet evolved into a fully developed system of theosophical doctrines, which became the core feature of the later Sufism.  The companions of Muhammad like Bilal, Salman Farsi, Ammar bin Yasir were the early mystics. Later with the spread of Islam Sufism flourished in Iraq, Syria, Egypt, Persia and Central Asia and gave birth to the renown Sufis like Rabia Basri, Hasan Basri, Junayd Baghdadi, Dhun Nun Misri, etc., around the 9 th and 10 th century. ,
As the early Sufi masters started teaching those in search of divine, a distinct tradition in the form of closely-knit communities centered around these masters flourished. The transformation of such communities into those, which shared a spiritual lineage, took place around the 11 th century and led to the formation of Sufi orders (silsilas), chains through which they would eventually link their disciples to Muhammad.  The early Sufi orders like Muhasibis, Qassaris, Junaydis, Nuris, Sahlis, Hakimis, Kharrazis, Sayyaris, and Tayfuris though limited to particular geographic locales were influential in the development of Sufi thought. Later major Sufi orders with a wider appeal were established around Sufi masters like Qadri by Abdul Qadir Jilani (Baghdad), Chishti by abu Ishaq Shami (Syria), Suharwardi by abu Najib Suharwardi, Yasavi by Ahmed Yasavi (Kazakhstan), Kubrawiya by Najmuddin Kubra (Central Asia), Rifai by Ahmed Rifai (Iraq), Shadhili by abul Hasan Shadhili (Morocco), Mevlavi by Jalal ud Din Rumi (Konya), Naqshbandhi by Bahauddin Naqshband (Bukhara), Nimatullahi by Nuruddin Muhammad Nimatullah (Syria) and Tijani by Abbas Ahmad ibn al Tijani (Algeria). The Sufi orders practiced presently run in hundreds but most of these represent the off shoots of the earlier ones. The 13 th century considered the golden age of Sufism was marked by the development of comprehensive mystical and theosophical doctrines of Sufism by the Sufi scholars like ibn ul Arabi of Spain, ibn ul Farid of Egypt and the popular Persian Sufi poet Jalal ud Din Rumi After the golden era the Arab-Muslim world produced only few notable Sufi scholars though the influence of Sufi orders continued to grow. The rise of Wahabism in the late 18 th and 19 th century that condemned Sufism as a heresy and the social and political reforms in the Muslim world during the 20 th century that considered Sufism as an impediment to development restricted the growth of Sufi philosophy and confined it to closely-knit circles of spiritual education. 
Apart from the Christian asceticism, Hinduism had a significant influence on Sufism both in terms of the philosophical basis and the meditation practices, which started much before Sufism reached the Indian subcontinent. The concept of existential unity of being (wahdat-ul-wujood) propounded by the ibn ul Arabi in the 13 th century bears striking similarity to the Advaita philosophy (unified Brahma-Jnana) of the Puranas (ancient Hindu religious texts). The concept of wahdat-ul-wujood has been a dominant philosophy in the later day Sufis which brought them closer to the Hindu mystics like Ramanand, Chaitanya, Ramanuja, Namdev, Mira Bai, Tukaram, and Ramdas, resulting in social movements like the Bhakti movement. The Sufis also incorporated some of the meditation techniques from the Hindu mystics like the breathing techniques to facilitate their Sufi practices. , In the 11 th century, Saifuddin Kaziruni from Iran was the first Sufi to settle in the Indian subcontinent.  Later the subcontinent became home to some of the great Sufi saints and scholars such as Moinuddin Chishti, Nizamuddin Awliya, Fariduddin Ganj-i-Shakar, and Qutbuddin Bakhtiar Kaki, whose teachings were influential in much of the growth and acceptance of Islam. ,
Sufism: The essence
The ultimate aim of the Sufi is communion with God through spiritual realization, which is achieved through the knowledge revealed by Quran (ilm) and the practice of Islam (amal).  Since its inception the Sufi philosophy has revolved around the concept of God and the ways and nature of communion with him. The early Sufis adhered strictly to the Quran in their interpretation of the concept of the God as infinite, eternal, unchangeable, creator, all-powerful, merciful and the cause of all existence. With the growth of Sufi philosophy, the concept of God changed from the one as the cause of all existence to the idea of God as the only real existence. This philosophy reached its ultimate in the concept of the wahdat-ul-wujood. ,
Sufis regards the soul as the agency for communication with God. It is the higher soul, as Sufis believe, created before any human being came into existence, consisting of heart (qalb), spirit (ruh), and conscience (sirr) that has the ability to know God. The sirr is regarded by many Sufis to represent the “secret shrine of God himself, wherein he knows man and man can know him.”  The heart (qalb) has an important place is Sufism and is considered to contain the divine spark that leads to spiritual realization. Sufis cherish the revelation by God that “I, who cannot fit into all the heavens and earths, fit in the heart of the sincere believer.”  For the heart (qalb) to reflect the truth as it is, it has to be cleansed of the rust of worldly influences.  The concept of the covenant (misaq) described in Quran “And (remember) when thy Lord brought forth from the children of Adam, from their reins, their seed, and made them testify of themselves (saying): Am I not your Lord? They said: Yea, verily. We testify. (That was) lest ye should say at the Day of Resurrection: Lo! Of this we were unaware” forms the basis of the Sufi philosophy of communion with God. , There is another soul (nafs) that Sufis regard as the seat of passions that creates hurdles in the communion of the higher soul with God. The nafs has to be transformed from nafs-e ammara (lustful soul; cf. Id) to nafs-e lawwama (self-blaming soul; cf. ego) and ultimately into nafs-e mutmaenna (peaceful soul; cf. super-ego) to return to truth. ,
Muhammad, has a special place in Sufism. The spiritual enlightenment or the ascendance of the higher soul for communion with God is believed to go through a chain of transmissions to Muhammad as through him only can the communion be achieved. Sufis refer to the saying of Muhammad “the first thing that Allah created was my light, which originated from his light and derived from the majesty of his greatness” as a basis for this belief. Sufis believe that the ascendance is possible only through the process of purification of the soul – the way (tareeqa). 
Tareeqa: The Sufi way
Muhammad, in a tradition related to him, described faith (iman) as “to acknowledge with the heart, to voice with the tongue, and to act with the limbs.” These three elements of faith are believed to correspond to the three aspects of the Sufi philosophy – sharia (act with the limbs), tareeqa (voice with the tongue), and haqeeqa (acknowledge with the heart). Sufis outwardly follow the sharia while on the way (tareeqa) for communion with the God (haqeeqa).  The Sufi tareeqa has been described as comprised of three stages – the stage of stations (maqamat), the stage of states (ahwal), and finally the stage of achievement (tamkin). The first stage represents the traveler’s (salik’s) striving for his lord and is achieved through self-mortification (mujahida). The salikis supposed to pass through the stations of repentance (tawba), piety (zuhd), trust in God (tawwakul), poverty (faqr), remembrance of god (zikr), patience (sabr), thankfulness (shukr), and contentment (rida) to reach the final station love (mohabba) of the first stage. The states (ahwal) are believed to result from the divine graces (tajalli) flowing from the God and occur during or after the first stage. The ahwal, as a matter of faith, are solely dependent on the God’s grace and cannot be induced by the Sufi. The final stage of achievement (tamkin) represents the end of the quest when the Sufi is supposed to receive the gnosis (marifa), the divine knowledge and become one with God. While on the tareeqa, the Sufi is first supposed to annihilate himself in his mentor (fana-fi-shaykh), then in Muhammad (fana-fi-rasul), and finally in God (fana-fi-allah) before he achieves eternal existence in his God (baqa). ,,,
Psychic Experiences in Sufism
Spiritual or psychic experiences are a quite common occurrence across cultures and religions. Though there are no specific studies related to Sufism, surveys reveals the percentage of people having had psychic experiences to range from 20% to 45%; the frequency varying with the time, gender, religion, etc.  Surprisingly the experiences share many features notwithstanding the differences in practices, beliefs, and cultures within which they occur. The psychic experiences occur in the domains of thought, perception and feeling (a complex perceptual experience) and share certain features regardless of the domain. The psychic experiences, partly based on individual accounts of Sufis, are immediate, usually transient, ineffable, unanalyzable, involving intimate association with a unique other self, transcending time, space and person, and felt as a deep sense of bliss. ,,
Historically, psychic experiences have been attributed to divine experiences, possession by demons, regarded as heresy and even insanity. The interpretations have varied with the political and religious environs of the times and have been influenced by the societal class of the claimant, the content of the experiences vis-à-vis the existing political and religious norms, gender, etc. The experiences have been interpreted to promote or discredit a particular political thought and even used as a plea for insanity. The case of two famous Sufis who claimed extreme forms of mystical experiences, Mansur al Hallaj and Bayazid Bastami needs a mention here. Both were and are considered as great Sufis on one hand and as heretics on the other and were even sentenced to death during their times for heresy. ,
Psychic experiences involve some experiences beyond the normal and Sufis claim these to be the source of ultimate knowledge (marifa or gnosis). The possibility of such knowledge yielding experiences has been questioned from philosophical and scientific perspectives. Kant rejected the possibility of the knowledge of ultimate as falling outside the sphere of human experience and hence its irrational nature. Sufi philosophers have argued for the possibility of such experiences as being only an extension of normal human experiences. The Sufi philosopher Fakhruddin Iraqi considered the possibility of these experiences as located in different orders of time and space (divine time and space) consequent to changes in the level of human consciousness.  The greatest impediment in the study of psychic experiences has been the subjective nature of these experiences, which contrasts with the classical objective nature of science.
Phenomenologically, the visions of the Sufis may be similar to “psychotic phenomena” like hallucinations (auditory, visual, etc.) and delusions. The knowledge yielding and the spiritual nature of these experiences have been questioned based on this semblance. It has been argued that all kinds of mystical experiences and hence religious beliefs have their origin in psychosis with the underlying assumption that all psychotic phenomena are abnormal. Psychotic phenomena (hallucinations and delusions) have been shown to be fairly common in the normal population as well as during spiritual experiences, which are apparently benign in nature. It has been argued that all psychotic phenomena are not abnormal and that abnormality needs to be redefined.  Considering these, there seems to be a need to examine the spiritual experiences beyond the disease model.
Neurobiology of Sufi experiences
The higher Sufi experiences of annihilation in the ultimate reality and eternal existence occur rarely but experiences such as transcendence, tranquility, sense of pleasure, and detachment occur more frequently. Though there are no specific neurobiological studies of Sufi experiences, it seems plausible to extrapolate the findings from studies of other spiritual experiences, given the similarity between such experiences. Such experiences have been reported in certain specific biological states such as near-death experiences, temporal lobe epilepsy, psychosis, and under the influence of drugs.  Structural and functional neuroimaging studies have shown the involvement of specific neural networks and neurotransmitters with these experiences. It seems pertinent to mention here that the elucidation of the underlying biological substrates for spiritual experiences does not prove or disprove their authenticity; it merely explains the mechanisms underlying these experiences. From a more philosophical perspective, it does, however, suggest a biological determinism and the unlikely extracorporeal nature of these experiences. ,
Increased religiosity and mystical experiences have been frequently associated with temporal lobe epilepsy. However, positive experiences are extremely uncommonly reported with temporal lobe epilepsy and many studies have failed to show any such relationship especially after controlling for brain damage and psychiatric comorbidity. ,, The temporal lobe, more specifically the right, is involved in emotional synthesis, spatial and time orientation, and strong emotional experiences, including the elevation of mood. As the mystical experiences involve modulations of these neuropsychological functions, mystical experiences have been attributed more to the right temporal lobe. , Other areas of the brain especially the dorso-lateral prefrontal cortex and posterior superior parietal lobule have been associated with preparedness and conscious identification, and the altered perception of self-experience during the spiritual experiences. ,
The neurotransmitters dopamine and serotonin have been associated with religiosity and spiritual experiences. The level of religiosity and the positive emotional aspects of religious and spiritual experiences may be modulated by dopamine. Self-transcendence, a trait associated with spirituality, has been found to be inversely related to 5HT receptor density. Again, it has been found that psychedelic drugs like D-lysergic acid diethylamide and psilocybin having serotonergic effects lead to spiritual experiences. ,, It would be interesting to see whether the administration of drugs with different profiles like antidopaminergics and antiserotonergics to mystics would abolish such experiences.
Sufism and Psychiatry
The term psychiatry is derived from the Greek words psukhe meaning psyche or soul and iatreia meaning healing; healing of the psyche or soul. Ironically the relationship between psychiatry and religion/spirituality has been a tumultuous one. The relationship has been greatly influenced by psychoanalysis; Freud considered religion pathological (neuroticism) and amenable to naturalistic explanations.  The hostile relationship that evolved from similar such ideas remained till the end of the 20 th century and has given way to the indifference of the 21 st century that it seems psychiatry can ill afford. As Fullford  argues, the conflict between psychiatry and religion/spirituality is an extension of the more fundamental conflict between science and religion/spirituality. The incorporation of the medical model into psychiatry led to its identification with the empirical sciences based on observation as the means of knowledge. Religion, on the other hand, is based on the “revealed” knowledge. As has been argued earlier in this paper, Sufi experiences share ground with the prophetic experiences of revelation and may provide the means to study religion “scientifically.” Sufism can thus provide the much-needed bridge between psychiatry and religion.
From a clinical perspective, psychiatry deals with the aspects of human life, which are governed by scientific facts as well as religious values.  Psychiatry by taking into account both the aspects of human life can develop into a discipline with a more holistic understanding of human behavior that can have implications for understanding and treatment of mental maladies. Psychiatry, thereby, is in need to shun the indifference and get actively engaged with the study of religion both from a philosophical and a clinical perspective.
Like other forms of spirituality, Sufism has resurged in the oriental as well as the occidental world in recent times. Sufi practices, or a belief in these, form an important part of the belief system of an increasingly large number of people both in the Muslim world and outside. The manifold increase in the mental-health related problems in recent years,  means that more and more such people will come into contact with mental-health related services. The contact of people with Sufi orientation with the mental health services gives rise to issues that need to be addressed at multiple levels.
Attitude of the mental health professionals toward patients’ belief systems: Heal thyself
There is evidence to show that a consideration of the spiritual needs of patients by the mental health professionals confers benefit to the patients.  Unfortunately, there are many misconceptions about religion and spirituality prevalent even among the mental health professionals. In a recent survey, Foskett et al.  showed that 45% mental health professionals felt that religion could lead to mental-health related problems. The evidence for this is mixed at the moment-studies show positive as well as the negative impact of the spiritual and religious beliefs and practices on the physical and mental well-being of people. ,,,,, Interestingly, studies have shown that the level of therapeutic satisfaction of religious individuals varies with the religiosity of the clinician; being less with the non-religious ones. 
An integral part of the current medical and mental health training involves inculcating a more objective attitude in the professionals that implicitly involves keeping their religious and spiritual beliefs and practices out of the clinical milieu. Consciously or unconsciously, as D’souza  has pointed out, this objectivity has strayed into keeping our patients’ religious and spiritual beliefs and needs out of the therapeutic milieu, thereby, failing the very objective of medical care – the individual well-being. This calls for an effort on the part of mental health professionals to understand the Sufi beliefs and practices as more and more such people are likely to come into contact with the mental health services in increasing geographical locales. However, due care has to be taken that mental health professionals do not impose or prescribe their religious or spiritual beliefs to their patients.
Assessment of Sufi beliefs and practices: History taking
However, comprehensive a mentally ill patient’s assessment might be, it most often does not include an assessment of spiritual beliefs and practices. This is ironical, especially in the Eastern context, where spiritual including Sufi beliefs and practices are an integral part of the cultural milieu. The seeds of this neglect lie mainly in the medical model of psychiatry that mental health professionals follow and partly in the lack of training, interest and time and discomfort with the subject. 
Apart from being a set of beliefs and practices, spirituality including Sufism claims the answers for some fundamental questions involving the life and death of people, which assume more significance during the time of illness.  It is not surprising, therefore, that religious and spiritual beliefs decrease the chances of suicide in mentally ill patients.  Assessment of the religious and spiritual including Sufi beliefs, therefore, should be a routine in the evaluation of mentally ill people so that a more patient-centered plan of management that invokes the individual patient’s strengths in the spiritual domain as well is formulated. 
The assessment of Sufi beliefs and practices has to be tailored to the individual patient. The assessment may best be deferred in an acutely ill patient unless Sufi concerns contribute to the acute condition. As a routine a brief assessment may be followed by a more thorough one on a need basis. Several brief assessment methods have been proposed for the assessment of spirituality in general that may help screen the patients for further in-depth assessment. , The four spiritual areas suggested by Koenig and Pritchett  to be screened in any psychiatric evaluation seem to be a good starting point but need to be modified for assessment of Sufi beliefs and practices. The initial assessment should include:
Faith: Importance of faith in day-to-day life? An increasing number of people from different religious faiths, besides Islam, are following Sufi beliefs and practices and hence considerable admixtures of beliefs and practices should be expected.Influence: Influence of faith on life, past and present? The Sufi practices of self-mortification may, apart from influencing the belief system, lead to significant changes in the practical life, which needs to be understood in proper perspective.Community: Affiliations with any religious or spiritual community? Almost all Sufi believers belong to one or the other lineage (silsila) which may significantly differ in terms of beliefs and practices from the other. An exploration of the lineage would provide a framework to understand a particular individual’s view point vis-à-vis health and illness.Address: Spiritual needs to be addressed? The Sufi teacher with whom the given individual has held the oath of allegiance (bay’a) may need to be incorporated in the treatment plan to fulfill the spiritual needs.An in-depth interview, from a clinical as well as a spiritual perspective, may follow this depending upon the needs of the patient as uncovered during the screening. Diagnostic considerations
Sufi beliefs and practices can contribute to mental health as well as illness. The benefits might range from providing a meaning to life, improved coping, a better quality of life and mental health, and speedy recovery from mental illnesses. On the other hand, these beliefs and practices may sometimes lead to acute breakdowns and may be causally related to the mental illness or contribute to the psychopathology.
Diagnostic and Statistical Manual of Mental Disorders fourth Edition-Text Revision(DSM-TR) provides for inclusion of spiritual and religious factors in two ways for individuals who do or do not have a mental illness. Religious and spiritual problems are given a V code under other conditions that may be a focus of clinical attention. Besides, under the multiaxial diagnostic system in DSM-IV-TR, axis IV describes psychosocial and environmental factors that may affect the diagnosis, treatment and prognosis of mental disorders (axis I and II), where spiritual and religious problems that do not meet the threshold for a V code can be placed. The religious and spiritual problems may include conversion to a new religion (including cults), a rejection of a prior religion or loss of faith, the intensification of beliefs and practices, experiences of guilt, mystical experiences, near-death experiences, and reactions to terminal illness. ,
Differentiating Sufi experiences from psychotic phenomena
Sufi experiences are diverse and include the domains of thought, perception, and feeling. Most of these experiences will never come to the clinical attention for two reasons: These experiences are firmly grounded in the spirituo-cultural milieu from which the person comes, and there is little in the way of dysfunction that these lead to. Of the experiences that come to the clinical attention, most can be differentiated based on the phenomenological grounds. The content of the experience – spiritual or psychotic, is culturally determined and may have no bearing on the diagnosis; it is the form of the experience which differentiates the two and may reveal the diagnosis. Differentiating the form from the content of the experience should prevent such confusions of the past as religious mania.  However, phenomena which resemble psychotic symptoms (delusions and hallucinations) on phenomenological (form) grounds do occur during apparently benign spiritual experiences. It is the differentiation of these experiences that gives rise to questions about the validity of the concept of mental illness on one hand and of the spiritual experiences on the other. Not surprisingly, therefore, extreme views have been argued about the nature of such experiences – labeling all of these as psychotic or spiritual depending upon one’s leanings. A more balanced view suggests that differentiation between such phenomenologically similar experiences may be possible based on their emotional value (spiritual experiences being mostly positive), overwhelming nature (spiritual experiences are less overwhelming), functional deterioration (spiritual experiences are less often dysfunctional), and as Jackson and Fulford  argue, the way in which the experience in question is embedded in the individual’s values and beliefs. Again, these differentiations are value laden and therefore, vary across cultures and are questionable.
Sufism and psychotherapy
Spiritual and religious beliefs form an important means of coping with stress for a large number of people but unfortunately this has received little attention by the mental health professionals. Recently, however, religion and spirituality have been incorporated into the therapeutic process and have shown promising results. , The assimilation of spirituality into the psychotherapeutic processes has been either in the form of an augmentation of an already existing therapeutic technique – spiritually augmented cognitive behavior therapy or the development of new techniques where spirituality itself forms the core – transpersonal psychotherapy. Though Sufi beliefs and practices have been incorporated into the transpersonal psychotherapy but there exists no literature about the incorporation of these into the cognitive behavior therapy models.
Spiritually augmented cognitive behavior therapy
Spiritually augmented cognitive behavior therapy is primarily a cognitive behavior therapy which incorporates the individual’s belief system, specifically the spiritual, to focus on the existential issues. The therapist works with the individual’s spiritual beliefs and practices like meditation, prayer, etc. but at no point attempts to instill his own beliefs or beliefs never held by the patient into the therapeutic process. The therapy spans over 10-16 sessions, each session lasting 45-70 min conducted once a week. The therapy has demonstrated efficacy in controlled trials with reduction of relapse and re-hospitalization in the treatment group.  The Sufi themes of patience (sabr), trust in God (tawwakul), contentment (rida), and God as the ever-forgiver may have a significant impact in changing the negative cognitive schemas and coupled with the Sufi practices of remembrance of god (zikr) and thankfulness (shukr) may provide an appropriate framework for spiritually augmented cognitive behavior therapy for the Sufi believers.
Transpersonal psychotherapy is based on the premise that human beings are essentially spiritual beings and hence the core qualities associated with spirituality form the goals of transpersonal psychotherapy.  The role of the therapist in transpersonal psychotherapy has been seen variously as ranging from a spiritual guide to a “fellow spiritual sojourner.” The therapist does not promote any specific spiritual philosophy and it is the client who leads and determines the spiritual content of the therapy.  Different spiritual practices, including Sufism, yoga, qigong, aikodo have been incorporated into the transpersonal psychotherapy. Transpersonal psychotherapy has been used for the treatment of abnormal grief, spiritual crises, psychotic disorders and substance use disorders. Transpersonal psychotherapy can provide the basis for engagement of traditional faith healers with the mental health care services and given the magnitude of people who seek traditional faith healers this can have significant public health impact. 
Sufism and mental health care services
A vast number of the mentally ill people in the community go untreated or seeks the help of spiritual healers in most of the developing countries. The reasons lie in the belief systems of the people which foster a spiritually oriented explanation of the mental illnesses and the practically non-existent mental health care services in most of the rural settings. The large number of mentally ill people thronging the shrines (dargah) of Sufi saints to seek cure is a testimony to this. The Erwadi (India) fire at the shrine of the Sufi saint Shaheed Valiyullah leading to the death of 28 mentally ill people should be a grim reminder of the cost of neglecting the incorporation of people’s spiritual beliefs into the mental health care services.  The incorporation of spiritual/Sufi elements into the mental health care services needs to be a two-fold process:
Incorporation of the spiritual/Sufi healers into the mental health care delivery system which may include basic training in identification of mental illnesses and appropriate referrals when needed.Incorporation of the spiritual/Sufi beliefs and practices into the therapeutic process which may increase the utilization of mental health services by a largely spiritually oriented population.
The integration of spiritual beliefs and practices into the mental health care delivery system needs efforts both at the organizational and individual level. Sensitization of the trainees in the mental health profession to spiritual issues needs to be given an impetus. The focus of the training should be on understanding of spirituality as an important part of the individual seeking help and a thorough understanding of the belief systems of the people in the practice area. 
Sufi beliefs and practices form an integral part of the belief system of not only the majority of the Muslim world but also the western world where it is gaining popularity. Sufism provides a vital link to the understanding of revelation – the source of religious knowledge in Islam as well as other Semitic religions, and influences the mental health of its believers and practitioners in a significant way. Unfortunately, there is little in terms of research based evidence to draw any conclusions in both these directions. There is a need for research to evolve scientifically sound means of incorporation of Sufi beliefs and practices into the mental health care system before any dogmas strike their roots. At the same time, mental health professionals should not slide into the role of preachers and start promoting the Sufi beliefs and practices; the role should rather be restricted to utilizing these beliefs and practices where it forms a part of the belief system.
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S Haque Nizamie
Central Institute of Psychiatry, Ranchi – 834 006
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