Sameera Shafiq  ( Department of Psychology, University of Gujrat, Gujrat, Pakistan. )
Zaqia Bano  ( Department of Psychology, University of Gujrat, Gujrat, Pakistan. )
Shahid Sharif Randhawa  ( Fauji Foundation Hospital, Rawalpindi, Pakistan. )
Khalid Hayat Khan  ( Department of Psychiatry, Fauji Foundation Hospital, Rawalpindi, Pakistan. )
Qurat-ul-Ain Muhammad  ( Department of Psychology, Foundation University Rawalpindi Campus, Pakistan. )
Abdullah Muhammad  ( International Islamic University, Islamabad, Pakistan. )

Several empirical researches imply that cognitive behaviour therapy can be effective in treating psychiatric disorders. In the context of Pakistan, some researches with Culturally Adapted Cognitive Behaviour Therapy were found to be effective for depression, anxiety, bipolar and psychotic disorders. The present study theoretically underpinned the model of Adapted Cognitive Behaviour Therapy (ACBT) based on the inclusion of Tasbeehs (Rosary) derived from the Quran and Sunnah to be fruitful in producing the desirable change in a single case of Dysthymia with anxious distress which was assessed with the help of the Urdu versions of Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Beck Hopelessness Scale (BHS) and Beck Scale for Suicidal Ideation (BSS). ACBT produced profound differences in pre-test and post-test scores in a patient. The Tasbeeh or Rosary could provide a therapeutic means for treating psychiatric illnesses irrespective of the religious and cultural differences.

 

Keywords: Anxiety Disorder, Cognitive Behaviour Therapy, Infertility, Major Depressive Disorder, Mood Disorder.

 

 

DOI: https://doi.org/10.47391/JPMA.1412

 

Introduction

 

Psychiatric problems particularly mood and anxiety disorders are found in high prevalence amongst infertile females (34%) in the Sub-continent.¹ These psychiatric illnesses are prominently more in non-reproductive women as compared to the general population of females with children in Pakistan.² The integration of cultural and religious teachings, along with cognitive behavioural therapy, produced better results in improving the dysfunctional attitudes of dysthymic disorders.³ Unlike religious therapy and religious cognitive behaviour therapy, all the principles and techniques of Cognitive Behavioural Approach are applied in the context of a single fundamental question, “Is there a God or not?”  It’s the use of Tasbeeh with one’s faith in a supreme power, while discovering an equilibrium between the imparting of both, the disease and the remedy as acts of God that accelerate the healing process. Belief in God is not a perception, it is a truth (Personal communication with Prof Ahmad). Unlike, Culturally Adapted Cognitive Behaviour Therapy,^4-6 ACBT is not a culture bound phenomenon rather it is an approach, irrespective of culture, religion and secularism, in which the use of Tasbeeh fosters the restorative balance of mental and physical health in a person who has faith or belief in existence of a Supreme Power.

The recitation of Tasbeehs (remembrance of God) on a daily basis is given to clients in sessions based on the rationale of the Quranic verses, ‘verily in the remembrance of Allah do hearts find rest; And (all) the Most Beautiful Names belong to Allah, so call on Him by them’.⁷ The Tasbeehs construed from the Hadith pertinent to management of sicknesses are: لاحولا ولاقوة الا (la hawla wala quwwata illa billah) ‘There is no strength and power besides the strength and power of Allah;                      (hasbi allah wa ni'mal wakeel) Allah is sufficient for us and what an excellent patron He is; and 40 times recitation of                                              

                                                     (la ilaha illa anta  subhanaka inni kuntu minaz zalimin) there is none worthy of Worship besides You. All purity belongs to You. Surely, I am from among the wrongdoers’.⁹

The tasbeehs             ‘Ya Salam (The Giver of Peace),        Ya Momin (The Giver of Faith)’⁸ have been grasped from the Quran. However, at the initial stage, cautionary measures are taken only in not giving Ya Salam to patients whose names started with “M” and Ya Momin is not given to patients whose names started with “S”, the insight derived from deep comprehension of Quran, Hadith and literature review of Islam. Ya Salam is used to impart peace from Allah and Ya Momin is linked with the faith to believe in God and this particular name of Allah means that He is the one who establishes faith in one’s heart. The effects of these Tabeehs could be experienced by anyone because it is based on Quranic principle, ‘Enjoin you Al-Bill (piety and righteousness and each and every act of obedience to Allah) on the people and you forget (to practise it) yourselves… Have you then no sense?’.⁶ Therefore, the hallmark criteria to impart Tasbeeh is to recite them by oneself and become familiar with their effects. By implementing these Tasbeehs in one’s lives and seeing their benefits, these could be recommended to others. There is no need either to meditate/concentrate or to perform wuzu (ablution) for Tasbeeh recitation and are supposed to be recited casually.⁴ Whosoever believes in the existence of God can recite these Tasbeehs irrespective of his or her religious orientation(Personal communication with Prof Ahmad). This case study has a great significance because it provided evidence that a parsimonious principle of Tasbeehs is applicable to observe the desirable change in treatment of dysthymia-chronic persistent depression that otherwise would have required 18 to 20 sessions when treated with any other mode of psychotherapeutic protocols.

 

Case Report

 

Patient was a 32-years-old female Muslim, masters degree holder who has been married to a widower with his three daughters and youngest son, belonging to a middle class family. She had been divorced, eight years ago. This was her second marriage and she had no children of her own in either marriage. Past events of experiencing domestic violence in her first marriage, struggling with the care taking of her paranoid brother, and the unjustified comparison made by her authoritarian father of her academic performance to her sister’s academic performance, all contributed to her major depression, which started six months into her first marriage in 2012. The pattern of chronicity exhibited remission and relapse in symptoms that followed since then, forcing the patient to seek treatment from pir-o-faqeer (faith healers) and physicians’ prescription on and off.

Her infertility and financial insecurities activated her depressive and anxious symptoms, one year after her second marriage. Though her second husband was a loving and reliable person, she suffered difficulties in financial facilitation by him, and in being accepted as a mother by his children (except to one 12 years-old-daughter). She came to the psychiatric ward of the hospital Fauji Foundation, Rawalpindi in January 2020, to seek the treatment for her presenting complaints: lack of sleep, poor appetite, breathlessness, numbness in hands and feet, crying spells, anger, and irritability, mood swings, and tiredness.

She was prescribed medications (Escitalopram 5mg in morning; bromazepam 1.5mg at night) by the psychiatrist and was referred to the psychologist for therapeutic sessions. She was not convinced to see the psychologist and resisted the meeting. She continued the medicines for one month but again suffered from the stream of above mentioned symptoms. This time in February 2020, she visited the psychiatrist for re-evaluation. Psychiatrist increased her dosage of medicine in prescribed range (Escitalopram 10mg in morning; bromazepam 3mg at night) and referred her to the psychologist for therapy. This time she was willing to take therapeutic sessions because medicines alone were not helping her properly and her husband encouraged her to seek additional help. She had primarily assumed that, if she would remain ill, her husband would eventually leave her. This served as a motivating force to see the psychologist. Written informed consent was taken. Her scores on Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Beck Hopelessness Scale BHS, and Beck Scale for Suicidal Ideation (BSS) in Urdu versions, were 38, 41, 15, and 5 respectively. Her DSM V Principal Diagnosis was 300.⁴ (F34.1) Dysthymia with anxious distress (moderate-severe), in partial remission, late onset, with persistent major depressive episode, severe.

 

Discussion

 

After reviewing all circumstances of her life, it was inferred that her core beliefs were “I am defective” and “I am vulnerable”, coming in “Helplessness” and “Unlovable” domains. Treatment focused on psychoeducating her about adherence to medication, seeking the cognitive behavioural model: theory and treatment, understanding depression, anxiety, and infertility. Here, beliefs in a Supreme Power were explored and role of religiosity in life was discoursed collaboratively and she was given Tasbeeh. She was taught the use of Thought Records to respond to negative automatic thoughts, erroneous cognitive distortions, and malfunctioning core beliefs with cognitive restructuring. Behavioural activation, breathing and relaxation exercises, and mindfulness intervened for the reduction of emotional and physiological arousal. Behaviour experiments and exposures reduced her social fear. She improved problem solving skills to deal with her financial issues with her husband in the light of the Shari’ah Law. She became assertive with her step daughters. ACBT helped her to see the influence of the spontaneous negative automatic thoughts on her emotions and behaviours and to cope effectively with them by responding through cognitive-behavioural techniques to reduce her symptoms of dysthymia and severe distress. Empirical researches^9-12 in Pakistan have shown that the participants have significantly improved in the symptoms of depression, anxiety, somatization, disability, bipolar, and psychosis by the application of Culturally adapted CBT in comparison to treatment with psychiatric medication.

In the beginning of the treatment when patient started to feel a little better, she refrained from taking medicines, reading her therapy notes, and reciting her Tasbeeh at once, with reoccurrence of symptoms. However, she did not miss her therapy session and came back with relapse. Psychoeducation was provided for comprehension of relapse phenomenon and the cognitive faulty thinking patterns were addressed again. The new core belief was reinforced by encouraging her to recite her Tasbeeh and maintain thought record with cognitive restructuring and cost-benefit analysis. The scores on Urdu BDI-II, BAI, BHI and BSS were 07, 11, 0, and 0 respectively thereby exhibiting reduction in her emotional instability and stubbornness.

 

Conclusions

 

Patient’s intrinsic motivation, collaboration, adherence to medication, and strong spiritual orientation with regular recitation of Tasbeehs enabled her to cope with dysthymia effectively within fourteen sessions (45 minutes each), two follow-ups and one booster-session. The evidence of improvements gained in this case study have implied for conduction of a randomized clinical and/or controlled trial studies with inclusion of Tasbeehs in future.

 

 

Acknowledgements: I am especially thankful to translators of BDI-II, BAI, BHS, and BSS namely, Prof. Dr. Sheikh Abdul Khaliq, Head, Department of Pharmacy Practice & Pharmaceutics Hamdard University, Karachi; Dr. Khisro Kaleem Raza HoD (Education) SUIT, Peshawar; and Dr. Nailah Ayub, Canada, respectively for granting permission to use the Urdu versions of these instruments. I am also grateful to Dr. Naushaba Naubahar (Fauji Foundation Hospital, Rawalpindi) and Ms. Sajida Kazmi (Senior Clinical Psychologist, Fauji Foundation Hospital, Rawalpindi) for their cooperation, and encouragement.

Disclaimer: This manuscript is the part of the author’s research project entitled, "Effectiveness of Adapted CBT for Psychiatric Disorders in Pakistan", approved by Institutional Ethical Committee of Fauji Foundation Hospital, Rawalpindi vide reference letter no. PF, SS/Adm-1, dated 23rd April, 2020.

Conflict of Interest: None.

Funding Sources: None.

 

 

 

 

 

 

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