A reflection on Dr Nadia Naser-Najjab’s article

Psychology and ethics: spirituality and cultural dimensions’ and ‘Islam, ethics and psychology

Ethics and Psychology: some tensions

Dr Naser-Najjab has astutely described Ethics and Psychology as interrelated because psychology is ‘concerned with human behaviour’ and, more specifically, human behaviour that ‘grants good mental health:’ accompanying the idea that individuals aim to suppress the Id and behave in ways that enable them to fit in ‘with the moral standards of society.’ The first thing that is striking when we look at this proposed relationship is the prominence of the idea that psychologists help construct behaviour that will be deemed to be acceptable within society and in turn produce happy content people, ‘and avoid experiencing conflict or trauma.’ This promotes the idea that the world around us is fine in general and that people are coping well when they supress their own individual desires, conflicts and traumas. This risks an unwitting perpetuation of the individualisation of distress and could disempower people in the long-term. Mental health difficulties are mediated by political, social and cultural factors, as well as war circumstances, which require us to question the outside world and engage with it critically. Ethics can serve as a stimulus for this process.

Ethics in psychology is less about individuals repressing their desires and difference from the society at large in order to fit better within that society, and more to do with normalising for individuals that vast differences exist between our subjectivities and how we think we ought to be in the world. That is, there are a variety of pressures, expectations and idealistic standards set by a limited few – the powerful – defining what the good life is, how we must achieve this, how we must live this and how we must look within this; the prevalence of eating disorders in both women and men is a case at hand. Psychology has been complacent in the legitimisation of these standards and unwittingly individualised and personalised conflicts and tensions individuals experience about their place and role in life, with an analysis of society and the outside world being absent. The roots of the ‘problem’ – whether that is immoral behaviour such as the perpetration of abuse or a mental health difficulty such as depression – are seen to lie within the individual themselves as a failing of their internal structure, strength and capacity. In this way individuals become the focus of treatment and change. Typically today when you read about recommended treatments it is often Cognitive Behavioural Therapy (CBT), which focuses on how an individual perceives their problem as opposed to the problem itself. The premise being that changing your perspective can change how you are dealing with the problem – your behaviour; an idea foregrounded in Buddhism. Whilst our perspective certainly does determine how we experience the world, a discussion of factors that constrain our perspective and experience tends to be squeezed out of the CBT approach. Personal disposition does play a role in how we cope with a problem. For example some of our patients manage the loss of a child with grief and acceptance whilst others never recover from it. This is certainly about individual sensibilities and worldview. Despite these individualisms, there is an assumption being made that we all have the same resources on which we draw in order to make the required shift in perspective. Cynically, overlooking inequalities in resources that are related to our well-being, such as social relationships, community belonging, material conditions and so on, might mean that there is not the same readiness for change in the society at large as is demanded of the individual themselves. This is a further reason for psychologists to be involved in socio-political contexts rather than explanations of poor mental health that problematize the individual. For example, a well-intentioned trauma counselling centre for people displaced in camps in Palestine would certainly be addressing a psychological need as people bear the difficulties of trauma and loss. CBT could be a useful approach in equipping individuals with skills and strategies to keep their symptoms at bay and develop some resilience in coping. However, these individuals are not automatically unwell until experiencing long standing oppression, aggression, conflict, humiliation, restriction on self-determination and basic resources, a lack of access to means of adequate healthcare, education and employment, and, most significantly, a lack of representation and power – a lack of voice. The use of mental health terms avoids highlighting the socio-political context, elevating depression rather than oppression. How we frame things is a matter of our ethics. Perhaps best characterised in psychological work with refugees and asylum seekers, where the impact of war, political and cultural atrocities and human loss, coupled with the dysfunctionalism of immigration policies and the asylum process, reveals how other factors mediate the experience of distress. The efficacy of therapy is often taken for granted by therapists. However an excessive emphasis on individual trauma can perpetuate a victim mind-set and medicalise what are social, cultural and political problems. Again, this is not to undermine the need for personal care, support and therapy, but there is a call for the clinical to be balanced with the social in order to be comprehensively ethical. The relationship between ethics and psychology is not just one about ‘encouraging ethical/moral behaviour’ in others – the patients – but also to do with the practitioners and the zeitgeist that they conform to. Ethics is less about fitting into the society around you and more about acknowledging lived ambivalences and differences in which assumptions about how we ought to live in this life are challenged and questioned. This can only be achieved by therapeutic approaches that emphasise individual and contextual psychology as the site of explanation.

 

Psychology and Islam: a personal view

It has just been proposed that ‘avoiding dissonance’ or achieving ‘self-contentment’ is not as salient as is tackling the lack of fit the majority of us experience trying to live in this world and recognising that it is a struggle to live in this life. In my work with people with mental health problems I often find that at the core of distress are concerns – anxiety – about existence: how to make life meaningful; how to make sense of life not coming together in the way that we desire it to; and how to accept this. A widely read and well respected therapist in psychotherapy, Irvin Yalom, has said that at the crux of most psychological difficulties lies an anxiety about death. For a while I took this view too, thinking that all of us are in existential crisis about life being temporary. Whilst I do still think that because we know life is temporary we become anxious about how to maximise it, we are also seeking meaning and purpose however temporary that might be. In this sense, each moment becomes important and whilst the desire to consolidate moments into hours, days, months and years is natural, it is in fact impossible and can lead to dissatisfaction and anxiety about the future. The Buddhist practice of mindfulness – moment to moment awareness without attachment and judgement – is a core part of numerous psychological interventions. This oscillation between attachment to positive moments and judgement towards negative moments is reminiscent of how as a Muslim I try to seek spiritual meaning in what pains me and offer gratitude for what is granted to me. Of course by nature I want to reject what pains me and attach to what gratifies me. Also by nature I want certainty and consciously as well as subconsciously I submerge myself in patterns that enable me to predict life. I think faith rocks these fundamental core needs. Faith requires us to live in the moment of distress equal to how we live in the moment of joy. Faith requires us to suspend our conscious as well as the subconscious need for creating our own patterns and ways of predicting outcomes and reducing uncertainty. It asks us to give into the unknown and to spend the unknown quantity of time we have in seeking harmony in this predicament. And we are not left without tools to help us do this: we are given rituals within our faith that can help ground this realisation and keep bringing us back to reflect on it, such as praying five times a day; we are given a holy book to guide us and from within which to formulate our questions and to which to take the challenges our mind has fought over; we are given the example and life account of the Messenger who personified the teachings we will spend our lifetime trying to grasp; and, finally, but certainly not least of all, we are given the promise that we are never voiceless to Him. With all of these tools in our bag, it is still understandable that we may find life to be a burden and unable to reconcile our distress. I am not advocating that a faith in God or a higher purpose compensates or makes easy trauma, loss or distress. What I would express is that how to make sense of suffering and how to live in spite of difficulties is a challenge for us all and the role of psychology is to help someone establish their tool bag for that journey, as well as offering insight and containment of the problem in the here and now. In this I am guided by my religious perspective that all experiences are temporary and to wrestle with them in order to force a release from them, can sometimes cause greater distress than the difficulty itself. This is not to advocate passivity in regard to our problems, but to find a way of engaging with them – understanding them – that offers meaning and a way forward. Whilst for me this comes from my faith and is my personal core framework through which I approach life, for others, the patients I see, it may be that another framework, a social, a family, an interpersonal, an economic, a humanitarian, a cognitive and so on, is more helpful. I would not take this to be in contradiction to the faith framework – they are different means to the same end. Therefore, I would encourage us to talk about ‘Islam’ and ‘Psychology’, rather than any move towards a concept of Islamic Psychology: psychology does not need to be Islamic in order to be in coherence with one’s faith, and Islam does not need to attach itself to a particular discipline in order for it to have credibility as offering something to that discipline. I would in contrast welcome some thought and pooling of ideas on what aspects of Islam are particularly in-tune with the human condition, its needs and frailties. When we think on this we quite quickly realise that it is difficult to find aspects of Islam that are not about the human condition. It is a faith that is sensitive to our humanity and does not goad us for wanting to predict and control the future.

 

Can there be culturally specific therapeutic models?

In contrast to Dr Naser-Najjab’s students who on the whole felt that Western philosophy and psychology do not relate to their culture and religious values, I feel that any opposing theoretical position can be a sounding board for critical reflection. It is possible to engage with the ideas of the ‘other’ without feeling threatened and with the intention to take from it what strengthens and helps clarify our own position. We would be naïve today to divide the world into Western and non-Western spheres as neither can be homogeneously differentiated or defined. Many things divide people from one another, whether individually or in groups, such as politics, wealth, ethnic identity, religious beliefs and traditions within a culture, which therefore also make universal ideas difficult to achieve. But many and even more fundamental things are common to all human beings: the need for safety, shelter, food and water, the society of other people, and the chance to flourish in well-being and capabilities. This is why the idea of some universal interests is such an important one. No single theoretical position whether Western or non-Western can be so self-constituted so as not to have overlapped with another theory or belief system or have something to say of relevance to a theoretical position constituted on a fundamentally different belief system. For example, I attended the talks by Dalai Lama when he visited my home city in Nottingham, UK, several years ago and found that much of what he said was beneficial to my perspective as a Muslim. I have never found my faith to have limited my need to exercise my curiosity in learning about different faiths, worldviews and philosophies; to exercise the talents and intelligence with which everyone is endowed.

The concerns expressed by Dr Naser-Najjab’s students foreshadow the argument that clinical psychology premised on a Western liberal theory of individuality and autonomy is of little use to non-Western patients for whom religious and traditional beliefs are of particular consequence. Culturally specific therapeutic models are seen as the most effective means of overcoming this problem. Whilst striking contrasts in the language used to describe emotions and mental health experiences among minority ethnic patients in the UK has been documented, in clinical psychology the construction of individual clinical formulation to inform understanding and treatment, includes cultural and religious beliefs, as well as others, determined by the individual as important to their experience. Clinical formulation draws together information from a range of areas such as family history, personal relationships and neuropsychological assessment to reach a rich understanding of the problems people present with. The formulation is constructed collaboratively with the patient according to her values, beliefs and experiences, so that they are individually-tailored. Individualism in clinical psychology is thus to treat someone according to her values and not based on those of her cultural group. However, the idea that clinical formulation alone is a model sufficiently equipped to deal with cultural beliefs and values different to our own may seem illusory; because it conceals the reality of discrimination, racism and exclusion well documented in UK mental health services. Critics have argued that it masks a project of cultural hegemony in the West whilst pretending to be universal. The concept of culturally specific models might be useful in tackling these issues, but there is a danger that such a model too will be over-extended. For example, how would such a model account for different interpretations of traditional norms? Who is to define what the traditional values of the group are to be? Would the determination of such values be a democratic decision-making process taking into account all voices of that group and then coming to a decision, or should the majority practice of that group be adopted automatically? We must recognise that the articulation of ethnic community identity involves a variety of possible category relations, including differences within the group, comparisons within the group, comparisons to other ethnic minority groups and the majority culture, which makes it difficult to define a culturally specific model to use with all members of a specific cultural group. Therefore, the model would need to be loose and general in scope so that we could capture individual nuances and differences. In this way there seems to be a need for individualism (a focus on the individual themselves) in even the culturally specific models. Dr Naser-Najjab pointedly requests that the centrality of religion and cultural traditions be realised and fostered within therapeutic work. Psychology’s need to be a science and the Western focus on secularisation, unfortunately, is not likely to make this a simple endeavour for the clinician.

 

A therapeutic approach to working with extremism

I would like to offer a final reflection on the important issue of Muslims and terrorism raised by Dr Naser-Najjab. I think clinical psychologists can offer a useful therapeutic space within counter-terrorism and towards understanding the journey made by someone towards this point. Forensic psychologists have long been working on psychological assessment of terrorists or those deemed to be susceptible to terrorism, to identify risk. In contrast, a clinical psychologist can offer reflective space that connects with the personal world and experience of individuals themselves. The current faith-based work that is undertaken within and outside of prisons focused on correcting religious misconceptions and poor integration into mainstream society, among other things, locates the problem within the individual and they become the site of dysfunction and deficit to be corrected by us. However in my experience of working clinically with a handful of young Muslim men who were erring towards extremist action, offering reflexive and collaborative space to explore their concerns and experiences was fruitful. Here, constructivist ideas and narrative therapy were particularly helpful. In brief, a constructivist/narrative approach holds that there are different ways of describing ourselves and we develop certain understandings about our self and the world based on interactions and discourses with others. The understanding is therefore malleable and rather than rooted within the individual it is an amalgamation of self and other interactions and our experience of the outside world. This flow of constantly changing narratives can cause us conflict because some experiences do not fit with the narratives through which we have understood our self – the dominant narrative. In the context of my work with young Muslim men exploring their life journeys and supporting them in discovering what experiences have led to the choices they have made and the particularly negative self-narratives that have contributed to those choices, has been useful. We were able to explore different aspects of the person and their history without explicitly pushing towards change and intervention, but producing change by the individual’s own emerging understanding and reflection. What stood out to me was the benefit of recognising the life stories of the individual, their ability to engage in reflection and their need for on-going support. All of which did lead to significant clinical and behavioural change.

 

In conclusion, we should not be bewitched by clinical psychology which is not itself a morally neutral practice. However, it does offer us the concept of clinical formulation which might enrich our understanding of human experiences because formulation is composed of elements such as religious, ethnical, national, social, and other identities that are essential to how the individual values their life. This does not mean that the clinician’s position and background would not lead them to privilege some identities and narratives of individuals over others, so that cultural and religious elements are given less space. But a clinician doing so is likely to act unjustly to the ethos of clinical formulation which should give prominence to what is important to the individual themselves. It is a framework I have valued for working out the complexity and diversity of problems that individuals can experience in trying to find a dignified place in their society.

 

Readers may find useful:

Socio-political issues affecting well-being and challenging the dominance of individually-focussed models of psychology: Critical Community Psychology (2011). C. Kagan; M. Burton; P. Duckett, R. Lawthom; A. Siddiquee. Wiley-Blackwell (UK).

Psychosocial intervention in war-affected societies: Therapeutising refugees, pathologising populations: international psycho-social programmes in Kosovo (2002). V. Pupavak. New Issues in Refugee Research, 59.

Narrative therapy: Maps of narrative practice (2007). M. White. W.W. Norton & Co, NY.

Working with refugees: Interview with Dr Saima Masud (2012): http://www.youtube.com/playlist?list=PL3ABBD9E459CC5A04.