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transcultural
psychiatry
March
2002
ARTICLE
Introduction
In the last two decades, the spiritual or psychoreligious aspects of mental
health have drawn much attention. This development was reflected in the
Vol 39(1): 130136[13634615(200203)39:1;130136;021658]
Copyright 2002 McGill University
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Method
All Malay patients with GAD, diagnosed according to the Diagnostic and
Statistical Manual of Mental Disorder, 3rd edition, revised (DSM-IIIR; APA,
1987) criteria, attending the Universiti Sains Malaysia psychiatric clinic for
first time during a 24-month study period were recruited for the study. All
the Malays were Muslims. The Structured Clinical Interview for DSM-IIIR
(SCID; Spitzer, William, Gibbon, & First, 1990) was used to generate DSMIIIR diagnoses. Two research psychiatrists (SMR and KA) conducted the
assessments. The severity of underlying anxiety was evaluated using the
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2.
3.
4.
5.
All the patients were followed up for six months. They were reviewed
weekly for the first four weeks, fortnightly until the twelfth week and then
monthly. The improvement of both groups was then compared statistically
using a Students t-test.
Results
In total 200 patients were recruited for the study; there was an equal
number of religious and non-religious patients. Thirty-five patients
(17.5%), 15 religious and 20 non-religious, did not complete the minimum
requirement of six months of therapy and were dropped from the study.
Thus, a final total of 165 patients formed the study sample. Forty-five of
the remaining 85 religious patients were in the study group, and 40 were
in the control group; of the remaining 80 non-religious patients, 42 were
in the study group and 38 were in the control group.
There were no significant differences in age, gender, socio-economic
status, duration of illness and severity of baseline HARS score between
patients in the study and control groups of both religious backgrounds.
Religious patients in the study group showed significantly more rapid
improvement in anxiety symptoms than those in the control group at the
fourth and twelfth weeks. The differences, however, became non-significant at the end of 26 weeks (Table 1). Among the non-religious patients,
TABLE 1
Hamilton Anxiety Rating Scale (HARS) score of the religious patients at various
stages of treatment
Weeks
Study group
Control group
(n = 45)
(n = 40)
Mean
SD
Mean
SD
t
0
4
12
26
20.8
12.5
4.8
2.9
4.1
3.6
2.5
2.1
21.6
14.9
6.4
2.2
4.3
3.9
2.7
1.9
0.88
2.96
2.84
1.61
ns, Non-significant.
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p-value
ns
< .01
< .01
ns
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there were no significant changes on the HARS score between the study
and control groups; all of them improved steadily to the end of the study
(Table 2).
TABLE 2
Hamilton Anxiety Rating Scale (HARS) score of the non-religious patients at
various stages of treatment
Weeks
Study Group
Control Group
(n = 42)
(n = 38)
Mean
SD
Mean
SD
t
0
4
12
26
21.5
13.5
5.2
2.3
4.2
3.5
2.3
1.5
21.0
14.3
5.8
2.5
4.1
3.8
2.5
1.7
1.35
1.63
1.42
0.91
p-value
ns
ns
ns
ns
ns, Non-significant.
Discussion
This study indicated the efficacy of spiritually and culturally oriented
cognitive therapy on anxiety patients who have strong Islamic backgrounds in addition to the standard treatment of GAD. The added
components did not have a significant effect on non-religious patients. The
religious patients who received RCP responded significantly faster than
those who received the standard treatment. However, at six months there
was no significant difference in improvement between the two groups.
Thus, the impact of the religiously oriented treatment appeared to
accelerate improvement but similar long-term gains were seen in both
treatment groups. The effect of incorporating religious and cultural
themes into psychotherapy as a separate treatment could be clarified if its
efficacy were compared with the control group who received basic cognitive-behaviour therapy (CBT) instead of drug, supportive psychotherapy
and/or relaxation exercise.
Blackburn and Davidson (1990) listed internal vulnerability factors as
one of the seven main areas required for formulation in cognitive therapy.
These include type of events that appear sensitive to the patient, and the
attitudes and beliefs that he holds about himself and his world. A strong
religious background was a prerequisite for the success of the psychotherapy. This group of patients managed to internalize religious values for
healing. We hypothesize that the efficacy of RCP in religious patients is
partly attributed to their strong commitment to religion. This provides
clinically effective cognitive schemata that enhance well-being, and rapidly
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lower distress (McIntosh, Silver, & Wortman, 1993). The schemata are
inferred from the implicit or explicit rules, which are exemplified in automatic thoughts.
The religious psychotherapy also helped religious patients to revive their
spiritual strength in coping with the illness. King and Dein (1998)
suggested that religion has many positive psychological effects. Those who
are religious may experience less psychological morbidity in the face of
adverse life events than those who are not religious. Another important
ingredient of the therapy is prayer. Praying five times a day is fundamental
for every Muslim regardless of their socio-economic status. Praying is a
form of meditation and therefore it promotes relaxation and general sense
of well-being (Woon, 1984).
Culture plays an important role in the concept, attitudes and stigma
attached to mental illness. Although belief in supernatural causes of mental
illness contradicts Islamic principles, the majority of Malay psychiatric
patients, regardless of their socio-economic status and religious background, attributed their illnesses to supernatural agents such as witchcraft
and possession by evil spirits (Razali, Khan, & Hasanah, 1996). In order to
maintain good rapport with patients and strengthen the therapeutic
relationship, we do not challenge patients on this issue. Acceptance of the
patients presentation and interpretation of their symptoms strengthens
the therapeutic relationship. The importance of understanding patient
cultural background to avoid emotional conflict has long been recognized
(Henderson & Primeaux, 1981; Murphy, 1973).
References
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Foundation.
Ahmad, S. (1999). Islam: Basic beliefs. Kuala Lumpur, Malaysia: A.S. Noordeen.
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mental disorders (4th ed.). Washington, DC: American Psychiatric Press.
Azhar, M. Z., & Varma, S. L. (1994). Religious psychotherapy in anxiety disorder.
Acta Psychiatrica Scandinavica, 90, 13.
Azhar, M. Z., & Varma, S. L. (1995). Religious psychotherapy in depressive patients.
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