x Abu Dhabi, UAESunday 23 July 2017

When cultural flexibility has more to offer than Freud

Ibn Hazm, a scholar in Islamic Spain during the 12th century, proposed a specific imagery-based exercise to combat chronic envy, having his patients visualise that the person they envied came from a distant land.

History is full of examples of those employing what we might consider psychotherapeutic interventions today. Socrates argued that through reason and logic he was able to transcend his predisposition to laziness and lechery. Ibn Hazm, a scholar in Islamic Spain during the 12th century, proposed a specific imagery-based exercise to combat chronic envy, having his patients visualise that the person they envied came from a distant land. People tend to envy those they view as similar to themselves, and Ibn Hazm's treatment was designed around that observation.

Despite the existence of psychotherapy throughout history and across cultures, the emergence of the psychoanalytic tradition in the latter part of the 19th century is typically viewed as the birth of modern psychotherapy. Rooted in the work of Sigmund Freud, psychoanalysis still reigns in the popular imagination as the archetypal talk therapy where people lay on couches, talking about their troubled childhoods.

But Freudian ideas can't always be applied across cultures, and they are also often at odds with people's religious and spiritual beliefs: how exactly would an Electra complex work in a polyandrous household? In today's multicultural societies ensuring that psychotherapeutic interventions are culturally appropriate is a vitally important challenge for those involved in the delivery of mental health care.

One therapy that appears to meet this challenge is cognitive behaviour therapy (CBT). Unlike psychoanalysis, CBT is very much focused on the present. One of its central therapeutic ideas is that dysfunctional but modifiable patterns of thinking are responsible for most psychological distress. Several researchers suggest that CBT can be culturally and spiritually modified. Dr David Hodge, an assistant professor at the Arizona State University School of Social Work, argues that CBT is highly congruent with Islamic values, given its emphasis on reason, logic, scientific exploration, consultation, and education, all widely endorsed within Islamic discourse.

Spiritual or cultural modification of CBT is achieved by drawing on concepts and examples from the client's own cultural or religious background. For example, in the context of CBT for depression, the widely know Islamic concept of "husn al dhun" can be an important reference. Husn al dhun is typically translated as "good opinion" - meaning that one should assume the best of people and situations. CBT holds that in many cases depression is maintained by the client holding negative opinions about themselves, other people, and the future.

Another part of CBT, encouraging people to make appropriate social comparisons, is also part of Islamic tradition, which encourages people to contemplate those less fortunate. Many social comparisons with those who have more are often implicated in depressive illness. "Self statements," where a patient articulates how they will challenge a dysfunctional belief that they want to modify, are also an important part of CBT. Dr Hodge advocates the adoption of self statements derived directly from the client's spiritual narrative. As an example of a self statement that might be aimed at countering dysfunctional beliefs related to achievement and acceptance, Dr Hodge suggests the following: "Although human approval and accomplishment are beneficial, they are not necessary for a productive life. As it says in the Quran, he who relies on Allah, Allah is enough for him."

Critics may question whether these modifications are clinically effective, but unless a client stays in therapy, no intervention is effective. And the evidence suggests that, with selected clients, spiritually and culturally attuned interventions are more acceptable and provide a better chance that a patient will buy in to the treatment and forge a stronger therapeutic relationship with their doctor. Studies undertaken in Saudi Arabia and Malaysia aimed at evaluating the efficacy of spiritually modified CBT have shown promising results. CBT clients who used the treatment showed clinically significant decreases in symptoms, were found to make faster progress, and complete treatment quicker.

As evidence-based psychotherapies such as CBT become more broadly embraced by the mental health care community in the UAE, it is important to ensure that clinicians are culturally competent, and flexible enough to adapt the content and frame of the therapy to best serve their clients. Justin Thomas is a psychologist in the department of health sciences at Zayed University in Abu Dhabi