[acb-hsp] Moving towards culturally competent practice with muslims

[J.Rayl]

Moving toward Culturally Competent Practice with Muslims: Modifying

Cognitive

Therapy with Islamic Tenets.

by David R. Hodge , Aneesah Nadir

Cultural

 competence is a fundamental social work value. The NASW Code of Ethics (2000) emphasizes

the provision of services that are sensitive to clients' cultures. Similarly, the

NASW Standards for

Cultural

 Competence in Social Work Practice (2001) underscores utilization of interventions

that are congruent with clients'

cultural narratives.

One particularly distinct cultural

 narrative is provided by Islam (Nadir & Dziegielewski, 2001; Williams, 2005). The

number of Muslims in the United States has increased dramatically over the course

of the past three decades (Carter & El Hindi, 1999; Hedayat-Diba, 2000; Hodge, 2005).

Although estimates vary significantly, somewhere in the range of 2 to 8 million Muslims

now reside in the United States (Hodge, 2005; Richards & Bergin, 2005; Smith, 2002).

Despite the size of the Islamic community, most practitioners appear to have been

exposed to relatively little content on Islam during their educational careers (Canda

& Furman, 1999; Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Furman, Benson, Grimwood,

& Canda, 2004; Heyman, Buchanan, Musgrave, & Menz, 2006; Murdock, 2004). Similarly,

a number of content analyses suggest that relatively little material exists in the

academic literature that would help equip therapists to engage in culturally competent

practices with Muslims (Cnaan, Wineburg, & Boddie, 1999; Hodge, Baughman, & Cummings,

2006; Nadir & Dziegielewski, 2001; Sheridan & North, 2004).

The lack of content represents a critical oversight. According to a variety of commentators,

many Muslims are hesitant to trust mental health professionals (Hedayat-Diba, 2000;

Hodge, 2005; Kelly, Aridi, & Bakhtiar, 1996; Mahmoud, 1996). Widespread belief exists

that helping professionals may not respect Islamic values. Many Muslims believe that

practitioners are unfamiliar with the values implicit in their therapeutic modalities.

Consequently, concerns exist that this unfamiliarity may result in the inadvertent

imposition of therapeutic strategies incongruent with an Islamic worldview.

To help practitioners select culturally relevant strategies, four common therapeutic

modalities are discussed in light of their level of congruence with Islamic values--psychoanalytic,

group, strengths based, and

cognitive. We suggest that, in principle, cognitive therapy

 is particularly congruent with Islamic discourse, but the self-statements central

to this approach need to be "repackaged" to reflect Islamic values. The research

on

cognitive therapy

 that has been modified to incorporate beliefs from clients' spiritual belief systems

is reviewed and suggestions are provided to help practitioners construct statements

that reflect Islamic values. Before beginning, however, we discuss some of the values

that tend to inform Western

therapy and Islam.

THE THERAPEUTIC ENTERPRISE--A VALUE-INFORMED PROJECT

The Western counseling project, like all other human constructions, is supported

by a particular set of epistemologically derived values regarding what constitutes

appropriate human functioning (Inayat, 2000; Kuhn, 1970). Rooted in the European

enlightenment, Western counseling affirms certain values at the expense of others

(Jafari, 1993). Selected characteristics are implicitly held up as representing norms

for healthy human functioning.

Among these characteristics are values such as individualism, self-determination,

independence, self-expression, egalitarian gender roles, explicit communication that

clearly expresses individual opinion, and identity rooted in work and love (Al-Abdul-Jabbar

& Al-Issa, 2000; Hodge, 2005). Western counseling, influenced by theorists such as

Freud (1966) and Maslow (1968), often emphasizes the role of the individual "self"

in

therapy

. Concepts such as self-actualization and self-efficacy are generally viewed positively

as are psychodynamically oriented insight strategies designed to raise clients' level

of self-understanding.

Just as the European enlightenment emphasized certain values, so too does Islam.

For the Muslim, these values are derived from Islam's scriptural text, the Qur'an,

and the traditions of the Prophet Muhammad, the Hadith. These primary sources serve

as the basis for the shari'a, or Islamic law or teaching. Perhaps the most widely

agreed on practices in Islam are the "five pillars" or obligatory practices (Esposito,

1988; Smith, 1999). The pillars include the declaration of faith (there is no god

but God and Muhammad is his messenger), the performance of ritual prayers (performed

five times a day), giving (typically 2.5 percent of accumulated wealth and assets

each year), annual fasting (from dawn to sunset 29 to 30 days during the month of

Ramadan), and a pilgrimage to Mecca (at least once during a Muslim's life if health

and finances permit).

The Islamic life, however, goes far beyond the practice of the five pillars. Foreign

to Islam is the notion of a dichotomization of life into a private dimension, which

is spiritual, and a public dimension, which is secular (Hodge, 2002; Nadir & Dziegielewski,

2001). Rather, life is seen as a holistic experience in which the spiritual informs

all aspects of existence (Carolan, Bagherinia, Juhari, Himelright, & Mouton-Sanders,

2000). For the devout Muslim, Islamic teaching forms the foundation upon which other

aspects of life are constructed (Waines, 1995). Accordingly, the Islamic narrative

has implications for essentially all dimensions of clients' lives.

Islamic teaching fosters the adoption of a number of widely held values among Muslims

(Hodge, 2005; Nadir & Dziegielewski, 2001; Williams, 2005). Among the more commonly

affirmed are community, consensus, interdependence, self-control, complementary gender

roles, implicit communication that safeguards others' opinions, and identity rooted

in religion, culture, and family. As mentioned above, these and other values suggest

a number of implications for social work practice, including the selection of various

practice modalities.

Before discussing these implications, however, it is necessary to underscore the

diversity that exists among self-identified Muslims (Eickehnan, 1998; Hodge, 2005).

In addition to a substantial number of native-born converts, the Islamic community

in the United States consists of Muslims from more than 80 nations (Nyang, Bukhari,

& Zogby, 2001). No single Islamic narrative exists, just as no single Western narrative

exists. Rather, a multiplicity of Islamic narratives exist, each shaped by local

cultures, race and ethnicity, political realities, degree of spirituality, and other

contextual factors, such as the degree of familiarity with the dominant culture.

Among those who have immigrated, length of time in the United States, generational

status, and the degree of acculturation to secular values add to this diversity.

Some second-generation Muslims in the United States at times may hold beliefs and

values that blend secular and Islamic values. Others may experience dissonance between

their families' Islamic values and those of their secular peer groups. Some may largely

adopt Western secular values, whereas others continue to practice mainstream Islamic

values (Ross-Sheriff, 2001; Smith, 1999).

This diversity should be kept in mind when considering the following material. Owing

to the wide range of views that exist in the Islamic community, a practice modality

that may be a good fit for one client may not be appropriate for another. Consequently,

the implications discussed should be considered tentative rather than absolute--a

working framework that should be tailored to fit the individual needs of clients.

IMPLICATIONS OF THE ISLAMIC NARRATIVE FOR SOME COMMON PRACTICE MODALITIES

Western counseling has developed many different practice modalities. A review of

this extensive collection is beyond the scope of this article. Rather, we restrict

our comments to some widely used modalities with which a certain degree of congruence

or incongruence with Islamic values exists.

Psychoanalytic Approaches

Psychoanalytic approaches, for example, may not be widely accepted among Muslims

(Al-Abdul-Jabbar & Al-Issa, 2000; Azhar & Varma, 2000; Banawi & Stockton, 1993).

In contrast to the individualism valued by Western counseling, Islam highlights the

importance of community (Al-Abdul-Jabbar & Al-Issa; Jafari, 1993). Rather than looking

inward to establish their identity, Muslims tend to look outward, grounding their

identity in religious teachings, culture, and family.

In contrast to many Western clients, the exploration of intrapsychic conflicts and

the elucidation of psychodynamic insights may hold little interest for Muslims. Although

psychoanalytic modalities point inward, Muslims tend to look outward. Community actualization

tends to be a priority over self-actualization.

Group Therapy

Similar to psychoanalytic approaches, some forms of group therapy

 also may be problematic for many Muslims (Al-Issa, 2000; Banawi & Stockton, 1993;

Carter & E1 Hindi, 1999). Although this might seem paradoxical given the Islamic

emphasis on community, group

therapy

 as practiced in Western settings often conflicts with a number of Islamic values.

For instance, some Muslims may feel uncomfortable sharing personal details in group

settings, particularly if members of the opposite gender are present. They may also

be reluctant to expose their faults, or those of others, to open scrutiny as is common

in group

therapy

. This value stems from the belief that if people conceal the weaknesses of others

in this world, God will conceal their weaknesses in the hereafter.

Although Muslims are community oriented, the orientation is typically toward other

members of the family and the Islamic faith. Consequently, groups composed of all

Muslims may find acceptance in some circumstances (Al-Krenawi, 1996; Al-Radi & Mahdy,

1994). The functions of such groups may be enhanced if they are composed of members

of the same gender and incorporate tenets taken from the Islamic faith. Given the

respect accorded to members of the extended family, it is often appropriate to include

extended family members in individual and family

therapy

 (Carolan et al., 2000).

Strengths-Based Approach

In contrast to psychoanalytic and group modalities, present-oriented strengths-based

approaches may find wider acceptance among Muslims (Al-Abdul-Jabbar & Al-Issa, 2000;

Al-Radi & Mahdy, 1994; Ali, Liu, & Humedian, 2004; Azhar & Varma, 2000; Daneshpour,

1998). In this approach, present strengths are identified and operationalized to

ameliorate problems. Because this perspective focuses on environmental and personal

strengths, it is a good fit for many Muslims.

The incorporation of environmental resources drawn from one's spirituality, family,

culture, and community is highly congruent with Islamic values. The focus is outward,

on external systems, rather than inward, on interior exploration. Concurrently, the

emphasis on strengths implicitly legitimizes Islamic practices, communicates respect,

and fosters trust.

A final modality that may be especially congruent with Islamic tenets is cognitively

based therapies (Al-Abdul-Jabbar & Al-Issa, 2000; Al-Radi & Mahdy, 1994; Banawi &

Stockton, 1993; Carter & E1 Hindi, 1999; Haynes, Eweiss, Mageed, & Chung, 1997).

Reason, logical discussion, education, and consultation are widely affirmed in Islamic

discourse. As discussed in the following section, these traits form the basis for

cognitive approaches.

COGNITIVE THERAPY

Cognitive therapy

 in its present form was developed and popularized by individuals such as Albert

Ellis (1962) and Aaron Beck (1976). A significant amount of literature exists on

this approach. According to Hepworth, Rooney, Rooney, Strom-Gottfried, and Larsen

(2006),

cognitive therapy

 is a major therapeutic modality in social work practice.

This approach, much like cognitive-behavioral therapy

, is based on reason, logical discussion, and education in a consultative manner

(J. Beck, 1995). More specifically, practitioners work with clients to identify irrational

beliefs or distorted thinking that underlies unproductive behaviors. Once identified,

the unhealthy thought patterns are replaced with self-statements that foster enhanced

functioning. Examples drawn from the work of Ellis (2000) and J. Beck are listed

in Table 1.

A substantial body of empirical evidence attests to the effectiveness of cognitive

therapy

 (A. Beck, 2005; Hepworth et al., 2006). In the area of evidence-based practice,

cognitive and cognitive

-behavioral

therapy

 represents one of the more researched modalities. It meets American Psychological

Association Division 12 criteria as a well-established treatment in the areas of

anorexia, anxiety and stress, binge eating disorder, bulimia, depression, generalized

anxiety disorder, and panic disorder (Chambless & Ollendick, 2001). In addition,

it meets criteria as a probably efficacious intervention in a number of other areas.

As implied earlier, the underlying principles on which cognitive therapy

 rests are congruent with Islamic values. The manner in which

cognitive therapy

 is operationalized in Western counseling, however, may strike some Muslims as overly

individualistic. As illustrated by the repeated use of "I" statements (see Table

1), Western

cognitive therapy

 tends to implicitly locate authority in the individual, autonomous self. This phraseology

conflicts with the more implicit communication style favored by many Muslims, as

well as the Islamic emphasis on the importance of community, and grounding one's

identity in the sovereignty of God.

Consequently, to increase the level of congruence with Islamic values, practitioners

may consider using spiritually modified

cognitive therapy

 (Azhar & Varma, 2000; Azhar, Varma, & Dharap, 1994, Wahass & Kent, 1997a). In other

words, the self-statements used in Western

cognitive therapy

 are replaced with statements drawn from Islamic teaching. A significant amount of

research exists on the use of spiritually modified

therapy with a number of spiritual traditions, including Islam.

Research on Spiritually Modified Cognitive Therapy

As mentioned earlier, spiritually modified cognitive therapy

 substitutes traditional self-statements with statements drawn from clients' spiritual

narratives. This approach has been used with clients from a number of different spiritual

traditions. Similarly, this model has been used to address a relatively wide array

of problems.

Cognitive therapy

 modified with Taoistic precepts has been used with clients wrestling with neurosis

(Xiao, Young, & Zhang, 1998). A

cognitive

 program modified with tenets drawn from the Mormon tradition has been used to treat

perfectionism (Richards, Owen, & Stein, 1993). A generic spirituality has been used

to help clients cope with stress (Nohr, 2000), depression (D'Souza, Rich, Diamond,

Godfery, & Gleeson, 2002; D'Souza, Rodrigo, Keks, Tonso, & Tabone, 2003), and bipolar

disorder (D'Souza et al., 2003).

Cognitive therapy

 modified with Christian beliefs has been used to address compulsive disorder (Gangdev,

1998) and, most notably, depression (Hawkins, Tan, & Turk, 1999; Johnson, Devries,

Ridley, Pettorini, & Peterson, 1994; Pecheur & Edwards, 1984; Propst, Ostrom, Watkins,

Dean, & Mashburn, 1992).

In addition, at least four studies have been conducted with Muslims. Three studies

used a pretest-posttest control group design with devout Muslims in Malaysia. The

studies explored outcomes with clients wrestling with anxiety disorders (n = 62)

(Azhar et al., 1994), depression (n = 64) (Azhar & Varma, 1995b), and bereavement

(n = 30) (Azhar & Varma, 1995a).

Clients who met the religious criteria and the DSM-III-R (American Psychiatric Association,

1987) criteria were randomly assigned to control and experimental groups. Both groups

were given traditional medication (for not more than eight weeks) and weekly psychotherapy

(for 12 to 16 weeks). The experimental group, however, was given additional treatment

in the form of

cognitive--behavioral therapy

 that had been modified to incorporate Islamic beliefs and practices (Azhar & Varma,

2000).

Client outcomes were assessed using standardized scales for anxiety and depression.

Assessment occurred at the start of treatment, at three months, and at six months.

No significant differences existed at the start of treatment in any of the studies.

The results for the first two studies--anxiety disorders and depression--were similar.

At three months, the experimental group recorded significantly lower levels of anxiety,

although by six months the gains achieved by the experimental group were matched

by those of the control group (that is, no significant difference at six months).

In other words, faster results were recorded with the Islamically modified

therapy

. In a managed care era when shorter treatment plans are becoming increasingly common,

this is an important finding.

In the bereavement study, assessment occurred at one, three, and six months. In this

study, Muslims in the experimental group showed a significant improvement in depressive

symptoms relative to the control group throughout the study. In other words, significantly

better results were obtained at one, three, and six months.

The fourth study, which is perhaps the most interesting, was conducted with Muslims

(n = 6) wrestling with schizophrenia in Saudi Arabia (Wahass & Kent, 1997a). A pretest-posttest

control group design was used. Clients were included in the study if they met the

International Statistical Classification of Diseases and Related Health Problems

(ICD-10) (World Health Organization, 1992) diagnosis for schizophrenia and had experienced

persistent auditory hallucinations for at least four years despite the administration

of antipsychotic medication.

Clients were randomly assigned to control and experimental groups. Although the antipsychotic

medication had been ineffective for at least four years, both groups continued to

receive the medication to control for any spontaneous changes that might occur on

account of the passage of time. The experimental group received spiritually modified

cognitive-behavioral therapy

. Assessment was conducted with the Structured Auditory Hallucinations Interview

(SAHI) (Kent & Wahass, 1996; Wahass & Kent, 1997b). Outcomes were measured at baseline,

after the nine-week treatment, and at the three-month follow-up. No differences existed

at baseline.

As expected, no change occurred in the control group. Similarly, no change occurred

with one member of the experimental group who was reluctant to implement the intervention

because the voices were perceived as benevolent.

The other two members in the experimental group, however, recorded significant decreases

across all nine variables assessed with the SAHI following treatment. These gains

were generally maintained at the three-month follow-up. In other words, a significant

decrease in symptoms occurred, including reductions in the frequency, loudness, and

hostility of the voices. This study is particularly interesting as it suggests that

spiritually modified

therapy

 may yield positive outcomes in situations in which antipsychotic medications alone

have proven ineffective.

A variety of designs were employed in these studies, which complicates attempts at

generalization. In general, however, the results recorded with spiritually modified

cognitive therapy

 were either similar, or superior, to the results achieved with traditional

cognitive therapy.

These findings are in accordance with the rationales informing culturally competent

practice. For instance, increasing the

cultural

 relevance of the intervention increases the likelihood that clients will implement

the intervention (Hepworth et al., 2006). If therapeutic strategies employed with

Muslims reflect Islamic values, then greater "buy in" may occur in individual, family,

and group settings (Al-Abdul-Jabbar & Al-Issa, 2000; Al-Radi & Mahdy, 1994; Banawi

& Stockton, 1993; Nadir & Dziegielewski, 2001).

Given the importance of Islamic teachings to practicing Muslims, designing culturally

relevant interventions may be particularly important. Some limited evidence suggests

that

cognitive therapy

 modified with Islamic tenets engenders relatively high levels of support from family

members and may even serve to counter the stigma associated with seeking help (Azhar

& Varma, 1995a). Because the therapeutic strategy reflects principles drawn from

the Qur'an and the traditions of the Prophet Muhammad, family members may be more

inclined to support and encourage implementation of the intervention.

In addition, motivation may be enhanced by tapping clients' spiritual motivation

(Jilek, 1994). In some cases, it is possible to construct interventions that convey

a spiritual duty. In such situations, clients' desire to address a given problem

may be leveraged by the knowledge that the intervention enhances their relationship

with God.

For these and other reasons (Hepworth et al., 2006), practitioners may wish to consider

Islamically modified

therapy

 when working with Muslims. This is particularly the case when working with clients

when they, or their families, are moderately to strongly practicing (Nadir & Dziegielewski,

2001). One indicator that suggests the applicability of Islamically modified

cognitive therapy

 is the degree to which clients practice the five pillars (Hodge, 2005). The greater

the level of salience of the pillars in clients' lives, the more practitioners may

wish to explore the possibility of spirituality modified

therapy

. To assist therapists in the construction of such interventions, the next section

provides some examples of

cognitive statements modified to reflect common Islamic values.

Before proceeding it should be mentioned that cognitive therapy

 encompasses more than interventions designed to alter clients'

cognitive

 distortions. As is the case with other well-developed therapeutic approaches,

cognitive therapy

 is a multidimensional modality (J. Beck, 1995). Although the following discussion

focuses on the construction of culturally modified self-statements, practitioners

should also be aware that other practice dimensions may need to be examined in light

of their level of congruence with Islamic values.

Cognitive Interventions Modified with Content from Islamic Tradition

To construct culturally relevant cognitive

 interventions, practitioners must engage in a three-step process (Hodge, 2004; Hodge,

2008). First, therapists must develop a good understanding of the precepts underlying

the self-statements typically used in Western

cognitive therapy

. It is important to be able to move beyond the wording in an attempt to grasp the

underlying concept the phrasing is attempting to convey.

Once this concept has been identified, it must be evaluated to ensure that it is

consistent with Islamic values. It is important to note that indicators of mental

health and pathology are not universal. As noted in the DSM IV-TR (American Psychiatric

Association, 2000), indicators can vary from culture to culture. A statement that

indicates mental health among secular Westerners may not indicate mental health among

Muslims. Consequently, in cases in which the concept runs counter to Islamic norms,

practitioners should consider discarding the concept and selecting one consistent

with an Islamic worldview.

Assuming the underlying concept is congruent with Islamic values, the concept is

then reworded in a manner that makes sense within the context of the Islamic narrative.

Put differently, the practitioner will want to phrase the concept in a way that reflects

Islamic norms. To summarize the process, the practitioner must remove the secular

cultural

 wrapping from the underlying therapeutic concept, evaluate the concept to ensure

its congruence with Islamic values, and then repackage the concept so that it resonates

with Muslims.

Some examples of spiritually modified cognitive

 interventions are provided in Table 2. In this table, the self-statements delineated

in Table 1 have been reworked to reflect Islamic values. It is important to note

that not all Muslims would agree with the phrasing used. As noted earlier, many Islamic

narratives exist within the broader Islamic worldview and concepts can be expressed

using different terminology. These statements, however, are likely to be consistent

with the worldview of many Muslims and serve to illustrate how traditional self-statements

can be transformed to reflect Islamic values.

For instance, item 1 in Table 1 might be used with individuals who are experiencing

problems with undisciplined lifestyles. In this understanding, the self-defeating

behaviors flow from the unproductive belief that instant gratification is absolutely

necessary. The unproductive schema is replaced with a salutary statement that emphasizes

self-control and the possibility of change. In other words, the underlying therapeutic

precept expressed in the traditional self-statement is that healthy functioning can

be achieved by adopting the belief that it is possible to change and live in a measured

and controlled manner.

Although this precept is congruent with Islamic values, the manner in which it is

expressed in Table 1 is inconsistent. In the traditional self-statement, individuals

are solely responsible for change. In other words, the individual functions as the

engine for change.

This understanding of change is inconsistent with Islam. At the core of the Islamic

worldview is the notion of the Islamic community's reliance on God (Hodge, 2002).

This is not to say that individuals have no role in the change process. >From an Islamic

perspective, people are responsible for change. The ultimate success of these efforts,

however, is dependent upon God.

Statement 1 in Table 2 has been modified to reflect an Islamic understanding of self-control

and change. The statement emphasizes a balance among personal agency, personal accountability,

and God's role in the transformation process. It focuses on the importance of relying

on God as part of successfully gaining self-discipline and making change in one's

life. Although an individual might experience a pull toward instant gratification,

God has given a Muslim the ability to choose and control one's self with his help.

In addition to referencing God, the statement also includes activities that may help

Muslims practice self-restraint. The statement incorporates basic Islamic practices,

such as fasting during Ramadan, as well as traditional fasting on Mondays and Thursdays

as ways to address

issues

 of self-control and self-restraint. This reminds Muslims of practices within their

tradition that can help to develop and maintain self-control.

Whereas the basic elements of self-control and change are consistent with the Islamic

belief system, modifying the statement to reflect Muslim beliefs and practices speaks

straight to the spiritual beliefs and practices of Muslims. Similarly, the use of

Islamic terms, such as Allah (God), nafs (self), and sunna (fasting), typically speak

directly to someone who is practicing Islam. As mentioned above, this phrasing may

encourage practicing Muslims to implement the intervention.

Similarly, statement 2 in Table 2 has been transformed to reflect common Islamic

values. The revised statement reflects the Islamic view that human beings have worth

because they are created by Allah. Thus, for the Muslim, one's worth is not based

on one's own self-declaration, but rather is based on an entity external to one's

self.

The third statement addresses the issue of raising one's tolerance for frustration,

a concept that is highly congruent with Islamic values. The Islamically modified

statement reframes trials in a manner similar to the traditional self-statement.

This new framing, however, provides an additional rationale for coping with frustrating

situations--namely that the situation represents a test provided by God. The statement

also incorporates two key Islamic teachings: that the trial will not exceed one's

ability to cope and that perseverance through the challenging situation is always

possible. These precepts can engender hope for a positive outcome in the midst of

difficult circumstances. Finally, the statement reminds Muslims to use the Islamic

practice of prayer as a way to deal with the frustrations and challenges of life,

implicitly reminding clients that God will help them deal with difficulties.

The remaining statements in Table 2 provide additional examples of spiritually modified

self-statements. As is the case with the preceding three Islamically modified statements,

the examples incorporate scripture, practices, and models that function to reinforce

the

cognitive

 precepts.

Some readers, however, may have concerns about constructing and using such self-statements

in clinical settings. For example, practitioners who are not Muslim may feel inauthentic

offering such statements to Muslim clients. In the following section, some brief

suggestions are provided to assist practitioners in constructing clinically useful

self-statements.

CONSTRUCTING ISLAMICALLY MODIFIED STATEMENTS

It is important to reiterate that the self-statements discussed earlier are illustrative

rather than prescriptive. In other words, the intent is not that they should be offered

to clients verbatim, but, rather, the intent is to illustrate what

cognitive

 interventions modified with content from the Islamic tradition might look like compared

with traditional secular self-statements.

The set of constructions depicted in Table 2 represent one of many possible formulations.

There are numerous ways to express therapeutic statements that reflect Islamic teaching.

As is the case with traditional self-statements, there is no single, right way to

articulate statements.

This latitude means that practitioners can work with clients to co-construct interventions

that resonate with Islamic values (Azhar & Varma, 2000). Indeed, as Beck and colleagues

(2004) emphasized, the collaborative co-construction of functional self-statements

is essential.

One way to facilitate this process is to ask questions designed to help clients articulate

pertinent aspects of their spiritual value system. As clients' spiritual beliefs

and practices are manifested, practitioners can interface their own understanding

of therapeutically relevant concepts into the discussion. Tentative hypotheses can

be suggested based on clients' articulation, which clients are encouraged to reject

or accept (Hodge & Bushfield, 2006).

Readers interested in additional information on this process may wish to read the

case example provided by Nielsen (2004). This well-documented case illustrated a

therapist of a different belief co-constructing interventions with a Muslim client.

The therapist, trained in the Rational Emotive Behavioral

Therapy

 (Ellis, 2000), developed interventions drawn from the client's spiritual beliefs

and values.

Practitioners can enhance their ability to construct Islamically modified interventions

by familiarizing themselves with the basic tenets of Islam and

cultural

 norms among Muslims (Nadir & Dziegielewski, 2001). By developing a working understanding

of Islam, they are better positioned to construct potentially relevant interventions.

In other words, such knowledge helps practitioners collaborate with clients in the

construction of therapeutic statements (Hodge & Bushfield, 2006).

Consultation with an Imam (a Muslim religious leader), a Muslim social work professional,

or another respected community member can also be helpful (Hall & Livingston, 2006).

A local Imam may be able to help workers identify concepts that are consistent with

Islam as well as language from Islamic teachings that support workers' interventions.

Similarly, when questions arise about the nature of clients' spiritual beliefs and

practices, collaboration with an Imam can be helpful in clarifying salutary beliefs

and practices (Gilbert, 2000).

CONCLUSION

Social workers will encounter Muslims in a variety of settings, including schools,

hospitals, and community mental health centers (Carter & El Hindi, 1999; Hodge, 2005;

Ross-Sheriff, 2001). In addition to the

issues

 commonly experienced by clients across cultures, practitioners may encounter immigrants

from Afghanistan, Bosnia, Iraq, Somalia, and other nations wrestling with trauma,

intergenerational family conflicts over acculturation, and post-9/11 anxiety (Ali

et al., 2004). In addition to the latter concern, American converts may be dealing

with estrangement from their extended family and adjustment to new practices and

traditions.

When faced with problems, some Muslims prefer the anonymity associated with seeking

professional help outside the Islamic community (Hall & Livingston. 2006). More commonly,

however, assistance is sought within the Islamic community (Ross-Sheriff, 2001).

Consequently, practitioners often see Muslims when they are in acute distress, after

options within the Islamic community have been exhausted and concerns about practitioners'

ability to respect their values have been mitigated by the felt need (Daneshpour,

1998).

In such tenuous situations, cultural

 competence is particularly important (Daneshpour, 1998). The use of modalities that

are inconsistent with clients' spiritual narratives can damage the therapeutic relationship

and even harm the client (Reddy & Hanna, 1998). Conversely, the use of practice strategies

that resonate with the client's reality helps to ease fears, build trust, and communicate

respect (Hodge & Bushfield, 2006). Such strategies safeguard client autonomy and

help ensure positive therapeutic outcomes (Hepworth et al., 2006). If interventions

make sense to clients, a greater likelihood exists that clients will be invested

in applying the interventions.

To help practitioners move toward culturally competent practice with Muslims, we

have examined a number of therapeutic approaches in light of their level of congruence

with common Islamic values. Psychodynamic and many group approaches may not always

be suitable with Muslims. Conversely, strengths-based modalities may find wider acceptance,

particularly those that use cognitively based interventions. These interventions,

however, should be modified with tenets drawn from Islamic teaching so that they

resonate with clients' worldviews.

Original manuscript received February 24, 2006

Final revision received October 4, 2006

Accepted December 22, 2006

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David R. Hodge, PhD, is assistant professor, Arizona State University and senior

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and encouragement.

Table 1: Cognitive Self-Statements

 1. Self-control and change

 Because I often make myself undisciplined and self-defeating by

 demanding that I absolutely must have immediate gratifications, I

 can give up my short-range "needs"--look for the pleasure of today

 and tomorrow and--seek life satisfactions in a disciplined way.

 2. Self-worth

 I am a worthwhile person with positive and negative traits,

 3. High frustration tolerance

 Nothing is terrible or awful, only--at worst--highly inconvenient.

 I can stand serious frustrations and adversity, even though I never

 have to like them.

 4. Acceptance of others

 All human beings are fallible, and therefore I can accept that

 people will make mistakes and do wrong acts. I can accept them with

 their mistakes and poor behaviors and refuse to denigrate them as

 human beings.

 5. Achievement

 I prefer to perform well and win approval of significant others,

 but I never have m do so to prove that I am a worthwhile person.

 6. Needing approval and love

 It is highly preferable to be approved of to be loved by

 significant people, and to have good social skills. But if I am

 disapproved of-, I can still fully accept myself and lead an

 enjoyable life.

 7. Accepting responsibility

 It is hard to face and deal with life's difficulties and

 responsibilities, but ignoring them and copping out is--in the long

 run much harder. Biting the bullet and facing the problems of life

 usually become easier and more rewarding ill keep working at it.

 8. Accepting self-direction

 I prefer to have some caring and reliable people to depend on, but

 I do not need to be dependent on such people. Nor do I have to find

 someone stronger than me to rely on.

 9. Self-acceptance

 If I fail at work, school, or some other setting, it is not a

 reflection on my whole being. (My whole being includes how I am as

 a friend, spouse, etc., as well as qualities of helpfulness,

 kindness, etc.). Furthermore, failure is not a permanent condition.

 Table 2: Cognitive Statements Modified with Islamic Tenets

 1. Self-control and change

 Allah (God) gave us free will, including the ability to control our

 nail (self). In addition, Allah has also given us many

 opportunities to practice self-control through fasting during

 Ramadan and weekly sunna (traditional) fasting on Mondays and

 Thursdays. These are ways, with the help of Allah, we can enhance

 our self-discipline and change for the better.

 2. Worth in Allah

 We have worth because we are created by Allah. We are created with

 strengths and weaknesses.

 3. High frustration tolerance

 Misfortunes and blessings are from Allah. Misfortunes are not

 terrible or awful, but rather a test. Although adversities may be

 unpleasant, we can withstand them. Allah tells us that He will not

 test us beyond what we can bear. By reminding ourselves of Allah's

 goodness, and engaging in regular dua (informal prayer), we can

 cope with life's challenges.

 4. Acceptance of others

 Because people are created with weaknesses, people will make

 mistakes. Islam tells us not to judge others for their

 shortcomings, but to accept people with their strengths and

 weaknesses.

 5. Achievement

 Although human approval and accomplishment is beneficial, they are

 not necessary for a productive life. As it says in the Qur'an, he

 who relies on Allah, Allah is enough for him.

 6. Needing approval and love

 Although it is nice to have the favor of others, we do not need the

 approval of others. True satisfaction and solace is found in our

 relationship with Allah. Our regular remembrance of Allah helps us

 to know that He loves us.

 7. Accepting responsibility

 Although facing difficulties is often challenging, Islam reminds us

 to persevere through adversity. No one else will bear our burdens

 for us. Each of us is responsible for our action and the path we

 choose.

 8. Accepting self-direction

 Allah has blessed us with His rizq (provisions/resources).

 Consequently, we are not dependent on others for our needs. Rather,

 we strive for tawakil (reliance on Allah for all our needs).

 9. Self-acceptance

 Allah knows us better than we know ourselves. Allah knows our

 weaknesses. Allah knows we make mistakes. Consequently, we can take

 comfort in Allah's mercy and accept ourselves with our strengths

 and weaknesses.

Questia, a part of Gale, Cengage Learning. www.questia.com

Publication Information:

Article Title: Moving toward Culturally Competent Practice with Muslims: Modifying

Cognitive Therapy with Islamic Tenets. Contributors: David R. Hodge - author, Aneesah

Nadir - author. Journal Title: Social Work. Volume: 53. Issue: 1. Publication Year:

2008. Page Number: 31+. COPYRIGHT 2008 National Association of Social Workers; COPYRIGHT

2009 Gale, Cengage Learning

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