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Suism and mental health

S. Haque Nizamie, Mohammad Zia Ul Haq Katshu1, N. A. Uvais2
Department of Psychiatry, Central Institute of Psychiatry, Ranchi, India, 1School of Psychology, University of Wales,
Bangor, UK, 2Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Delhi, India

AbstrAct

Human experience in, health and disease, always has a spiritual dimension. Spirituality is accepted as one of the deining
determinants of health and it no more remains a sole preserve of religion and mysticism. In recent years, spirituality
has been an area of research in neurosciences and both in the understanding of psychiatric morbidity and extending
therapeutic interventions it seems to be full of promises. Suism has been a prominent spiritual tradition in Islam deriving
inluences from major world religions, such as, Christianity and Hinduism and contributing substantially toward spiritual
well‑being of a large number of people within and outside Muslim world. Though Suism started in early days of Islam
and had many prominent Suis, it is in the medieval period it achieved great height culminating in many Sui orders and
their major proponents. The Suism aims communion with God through spiritual realization; soul being the agency of
this communion, and propounding the God to be not only the cause of all existence but the only real existence. It may
provide a vital link to understand the source of religious experience and its impact on mental health.

Key words: Mental health, psychotherapy, Suism

INTRODUCTION etiology, meaning and the modalities of redressal. It seems

Humans have always had the quest to know themselves, to
know the world around them, and to know their place in the
world. The history of mankind is replete with people who
like Mitya in The Brothers Karamazov are “haunted by a great
unsolved doubt.”[1] This quest has led man from the dogmas
of religion to the discourses of philosophy and finally to the
empirical sciences. Though we have made some progress in
understanding ourselves vis‑à‑vis the nature, the answers
still remain elusive. Spirituality, whether associated with
particular religions or otherwise, has been practiced since
ages and claims to offer answers to the “unsolved doubts.”
The recent years have witnessed a surge of interest in
spirituality and the advancements in neurosciences offer
an opportunity to understand it from a more scientific
standpoint and put it in proper perspective. Across cultures,
spirituality forms an important part of belief systems of
majority of the people. It affects the mental well‑being
and the understanding of mental illnesses in terms of the
Address for correspondence: Prof. S. Haque Nizamie,
Central Institute of Psychiatry, Ranchi ‑ 834 006, India.
E‑mail: sh.nizamie@gmail.com
important that mental health professionals should be aware
of the ways spirituality affects the mental well‑being of
individuals in both health and disease states. This paper will
outline the basic foundations of Sufism – a particular kind
of Islamic mysticism, how it affects the mental well‑being
of individuals associated with it, and its interface with
clinical psychiatry in terms of implications for diagnosis and
management.
SUFISM
The need to know Sufism
Human cognitions and behaviors are determined largely
by a set of facts and values. The facts are mostly derived
from the science and the values have their origin in
religious or non‑religious philosophies such as humanism
and existentialism.[2] Spirituality being an integral part
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DOI:
How to cite this article: Nizamie SH, Katshu MZ, Uvais NA.
10.4103/0019‑5545.105535
Sufism and mental health. Indian J Psychiatry 2013;55:215-23.

Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013 S215
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Nizamie, et al.: Suism and mental health
of most of the religious philosophies provides the value
system for the majority of people and thereby influences
their well‑being. Recognizing this, the spiritual well‑being,
in accordance with the social and cultural patterns, was
accepted as one of the important determinants of health
by the World Health Organization during the 37th World
Health Assembly in 1984.[3] Spiritual teaching has already
found its place in the curriculum of many medical schools
in the Western world.[4,5] From a mental health perspective,
spirituality seems to have a far greater role as these operate
on the same ground – the brain or as some would like it call
it the mind or the soul. In fact, there are studies that show
positive as well as the negative impact of the spiritual and
religious beliefs and practices on the physical and mental
well‑being of people who subscribe to spiritual or religious
practices.[6‑11] Sufism, having a large following both in the
Muslim world and outside coupled with migration of large
numbers of people from eastern Sufi oriented lands to the
west, is a rapidly growing form of spirituality that needs
to be understood in terms of its impact on the mental
well‑being of its followers and the potential interactions in
the mental health care clinical settings.
From a more philosophical point of view, Sufism provides
an opportunity to understand the source of religious
knowledge in general and Islamic knowledge (revelation)
in particular. In Sufi traditions, it is believed that Sufis can
have similar knowledge revealing experiences as are the
source of religious knowledge in the form of revelation
of the Quran (the scripture of Islam) to Muhammad (the
Prophet of Islam). The study of these Sufi experiences
which share phenomenological ground with the prophetic
experiences of revelation provides a possibility for the
scientific study of the sources of religious knowledge.
[12,13]
From day‑to‑day clinical practice to research, the
study of the normal and abnormal perceptual/experiential
phenomena and its implications form an integral part of
the mental‑health related sciences and puts the students of
mental‑health sciences in a coveted position to study the
Sufi experiences.
Historical background of Sufism
The term Mysticism had its beginning in the mystery cults
of the Greeks, which involved a close circle of devotees
who because of their innate capacity were believed to have
the knowledge of the divine revealed to them. Etymology
aside, mysticism has been practiced since ages across all
the cultures and has been a vital part of the major religions
of the world. Perhaps it represents an innate desire of the
man to understand himself and the world around. All forms
of mysticism aspire for a union with the divine and believe
that it is only possible through the purification of soul to
receive direct knowledge and revelation from the divine.[14]
Islam began in 610 AD and established itself through the
teachings of Muhammad believed to be revealed to him
by God through the archangel Gabriel primarily among
S216 Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013
the Arab pagan and Christian communities. The close
contact between the Muslim and the Christian communities
during the formative years of Islam had its influence on
the development of the Sufism – the mystic traditions of
Islam. Sufism established itself within the traditions of the
Islam as laid down in the Quran believed to be revealed
to Muhammad by God. The Sufis believe that communion
with God is possible through Muhammad, who was
the recipient of the knowledge of the heart (Ilm‑e‑Sina)
besides the outer knowledge (Ilm‑e‑safina). Ali, one of the
Muhammad’s companions and son‑in‑law, is considered
to be the first Sufi to whom the Ilm‑e‑Sina was revealed by
Muhammad to be taught to those capable of understanding
it. Contrary to the mainstream, some schools of thought
in Islam denounce Sufism as heretical and consider it an
innovation in Islam.[15,16] However, the concept of God, the
possibility of esoteric knowledge and the ways to access
God through purification of self by means of prayer, fasting
and repentance that form the foundations of Sufism find
their source in the Quran and the teachings of the prophet
known as Hadith.[14]
Sufism in the beginning was primarily an individual
endeavor. The Sufis would usually live in isolation practicing
self‑mortification and were distinguished by a cloak of
wool (Suf), a tradition of Muhammad, which is believed to
be the origin of the word Sufi.[15,17] A group of such devouts
lived a life of poverty and incessant prayer and fasting on a
stone bench in front of Muhammad’s mosque. These people
of the bench (Ashab‑e‑suffa), 45 to over 300 in number, were
given to much weeping and repentance and are believed
to be the origin of the Sufism.[18] However, the name Sufi
was given to such ascetics only around the second century
of death of Muhammad. The Sufis in the early period were
primarily ascetics and Sufism had not yet evolved into a fully
developed system of theosophical doctrines, which became
the core feature of the later Sufism.[14] The companions of
Muhammad like Bilal, Salman Farsi, Ammar bin Yasir were
the early mystics. Later with the spread of Islam Sufism
flourished in Iraq, Syria, Egypt, Persia and Central Asia and
gave birth to the renown Sufis like Rabia Basri, Hasan Basri,
Junayd Baghdadi, Dhun Nun Misri, etc., around the 9th and
10th century.[16,19]
As the early Sufi masters started teaching those in search
of divine, a distinct tradition in the form of closely‑knit
communities centered around these masters flourished.
The transformation of such communities into those,
which shared a spiritual lineage, took place around the
11th century and led to the formation of Sufi orders (silsilas),
chains through which they would eventually link their
disciples to Muhammad.[20] The early Sufi orders like
Muhasibis, Qassaris, Junaydis, Nuris, Sahlis, Hakimis,
Kharrazis, Sayyaris, and Tayfuris though limited to particular
geographic locales were influential in the development of
Sufi thought. Later major Sufi orders with a wider appeal
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were established around Sufi masters like Qadri by Abdul
Qadir Jilani (Baghdad), Chishti by abu Ishaq Shami (Syria),
Suharwardi by abu Najib Suharwardi, Yasavi by Ahmed
Yasavi (Kazakhstan), Kubrawiya by Najmuddin Kubra (Central
Asia), Rifai by Ahmed Rifai (Iraq), Shadhili by abul Hasan
Shadhili (Morocco), Mevlavi by Jalal ud Din Rumi (Konya),
Naqshbandhi by Bahauddin Naqshband (Bukhara),
Nimatullahi by Nuruddin Muhammad Nimatullah (Syria) and
Tijani by Abbas Ahmad ibn al Tijani (Algeria). The Sufi orders
practiced presently run in hundreds but most of these
represent the off shoots of the earlier ones. The 13th century
considered the golden age of Sufism was marked by the
development of comprehensive mystical and theosophical
doctrines of Sufism by the Sufi scholars like ibn ul Arabi
of Spain, ibn ul Farid of Egypt and the popular Persian Sufi
poet Jalal ud Din Rumi After the golden era the Arab‑Muslim
world produced only few notable Sufi scholars though the
influence of Sufi orders continued to grow. The rise of
Wahabism in the late 18th and 19th century that condemned
Sufism as a heresy and the social and political reforms in
the Muslim world during the 20th century that considered
Sufism as an impediment to development restricted the
growth of Sufi philosophy and confined it to closely‑knit
circles of spiritual education.[16]
Apart from the Christian asceticism, Hinduism had a
significant influence on Sufism both in terms of the
philosophical basis and the meditation practices, which
started much before Sufism reached the Indian subcontinent.
The concept of existential unity of being (wahdat‑ul‑wujood)
propounded by the ibn ul Arabi in the 13th century bears
striking similarity to the Advaita philosophy (unified
Brahma‑Jnana) of the Puranas (ancient Hindu religious
texts). The concept of wahdat‑ul‑wujood has been a dominant
philosophy in the later day Sufis which brought them closer
to the Hindu mystics like Ramanand, Chaitanya, Ramanuja,
Namdev, Mira Bai, Tukaram, and Ramdas, resulting in
social movements like the Bhakti movement. The Sufis also
incorporated some of the meditation techniques from the
Hindu mystics like the breathing techniques to facilitate
their Sufi practices.[21,22] In the 11th century, Saifuddin
Kaziruni from Iran was the first Sufi to settle in the Indian
subcontinent.[23] Later the subcontinent became home to
some of the great Sufi saints and scholars such as Moinuddin
Chishti, Nizamuddin Awliya, Fariduddin Ganj‑i‑Shakar, and
Qutbuddin Bakhtiar Kaki, whose teachings were influential
in much of the growth and acceptance of Islam.[15,16]
Sufism: The essence
The ultimate aim of the Sufi is communion with God
through spiritual realization, which is achieved through
the knowledge revealed by Quran (ilm) and the practice of
Islam (amal).[24] Since its inception the Sufi philosophy has
revolved around the concept of God and the ways and nature
of communion with him. The early Sufis adhered strictly to
the Quran in their interpretation of the concept of the God
Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013
as infinite, eternal, unchangeable, creator, all‑powerful,
merciful and the cause of all existence. With the growth of
Sufi philosophy, the concept of God changed from the one
as the cause of all existence to the idea of God as the only
real existence. This philosophy reached its ultimate in the
concept of the wahdat‑ul‑wujood.[14,22]
Sufis regards the soul as the agency for communication with
God. It is the higher soul, as Sufis believe, created before any
human being came into existence, consisting of heart (qalb),
spirit (ruh), and conscience (sirr) that has the ability to know
God. The sirr is regarded by many Sufis to represent the
“secret shrine of God himself, wherein he knows man and
man can know him.”[18] The heart (qalb) has an important
place is Sufism and is considered to contain the divine
spark that leads to spiritual realization. Sufis cherish the
revelation by God that “I, who cannot fit into all the heavens
and earths, fit in the heart of the sincere believer.”[25] For
the heart (qalb) to reflect the truth as it is, it has to be
cleansed of the rust of worldly influences.[26] The concept of
the covenant (misaq) described in Quran “And (remember)
when thy Lord brought forth from the children of Adam,
from their reins, their seed, and made them testify of
themselves (saying): Am I not your Lord? They said: Yea,
verily. We testify. (That was) lest ye should say at the Day of
Resurrection: Lo! Of this we were unaware” forms the basis
of the Sufi philosophy of communion with God.[16,27] There is
another soul (nafs) that Sufis regard as the seat of passions
that creates hurdles in the communion of the higher soul
with God. The nafs has to be transformed from nafs‑e
ammara (lustful soul; cf. Id) to nafs‑e lawwama (self‑blaming
soul; cf. ego) and ultimately into nafs‑e mutmaenna (peaceful
soul; cf. super‑ego) to return to truth.[14,26]
Muhammad, has a special place in Sufism. The spiritual
enlightenment or the ascendance of the higher soul for
communion with God is believed to go through a chain
of transmissions to Muhammad as through him only can
the communion be achieved. Sufis refer to the saying
of Muhammad “the first thing that Allah created was my
light, which originated from his light and derived from the
majesty of his greatness” as a basis for this belief. Sufis
believe that the ascendance is possible only through the
process of purification of the soul – the way (tareeqa).[16]
Tareeqa: The Sufi way
Muhammad, in a tradition related to him, described
faith (iman) as “to acknowledge with the heart, to voice
with the tongue, and to act with the limbs.” These three
elements of faith are believed to correspond to the three
aspects of the Sufi philosophy – sharia (act with the limbs),
tareeqa (voice with the tongue), and haqeeqa (acknowledge
with the heart). Sufis outwardly follow the sharia while on
the way (tareeqa) for communion with the God (haqeeqa).
[24]
The Sufi tareeqa has been described as comprised of
three stages – the stage of stations (maqamat), the stage of
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states (ahwal), and finally the stage of achievement (tamkin).
The first stage represents the traveler’s (salik’s) striving for his
lord and is achieved through self‑mortification (mujahida).
The salikis supposed to pass through the stations of
repentance (tawba), piety (zuhd), trust in God (tawwakul),
poverty (faqr), remembrance of god (zikr), patience (sabr),
thankfulness (shukr), and contentment (rida) to reach the final
station love (mohabba) of the first stage. The states (ahwal)
are believed to result from the divine graces (tajalli) flowing
from the God and occur during or after the first stage. The
ahwal, as a matter of faith, are solely dependent on the God’s
grace and cannot be induced by the Sufi. The final stage
of achievement (tamkin) represents the end of the quest
when the Sufi is supposed to receive the gnosis (marifa), the
divine knowledge and become one with God. While on the
tareeqa, the Sufi is first supposed to annihilate himself in
his mentor (fana‑fi‑shaykh), then in Muhammad (fana‑fi‑rasul),
and finally in God (fana‑fi‑allah) before he achieves eternal
existence in his God (baqa).[14,16‑18]
PSYCHIC EXPERIENCES IN SUFISM
Different perspectives
Spiritual or psychic experiences are a quite common
occurrence across cultures and religions. Though there are
no specific studies related to Sufism, surveys reveals the
percentage of people having had psychic experiences to
range from 20% to 45%; the frequency varying with the time,
gender, religion, etc.[28] Surprisingly the experiences share
many features notwithstanding the differences in practices,
beliefs, and cultures within which they occur. The psychic
experiences occur in the domains of thought, perception and
feeling (a complex perceptual experience) and share certain
features regardless of the domain. The psychic experiences,
partly based on individual accounts of Sufis, are immediate,
usually transient, ineffable, unanalyzable, involving intimate
association with a unique other self, transcending time,
space and person, and felt as a deep sense of bliss.[14,13,28]
Historically, psychic experiences have been attributed to
divine experiences, possession by demons, regarded as
heresy and even insanity. The interpretations have varied
with the political and religious environs of the times and
have been influenced by the societal class of the claimant,
the content of the experiences vis‑à‑vis the existing political
and religious norms, gender, etc. The experiences have been
interpreted to promote or discredit a particular political
thought and even used as a plea for insanity. The case of
two famous Sufis who claimed extreme forms of mystical
experiences, Mansur al Hallaj and Bayazid Bastami needs a
mention here. Both were and are considered as great Sufis
on one hand and as heretics on the other and were even
sentenced to death during their times for heresy.[29,30]
Psychic experiences involve some experiences beyond the
normal and Sufis claim these to be the source of ultimate
S218 Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013
knowledge (marifa or gnosis). The possibility of such
knowledge yielding experiences has been questioned from
philosophical and scientific perspectives. Kant rejected the
possibility of the knowledge of ultimate as falling outside
the sphere of human experience and hence its irrational
nature. Sufi philosophers have argued for the possibility
of such experiences as being only an extension of normal
human experiences. The Sufi philosopher Fakhruddin
Iraqi considered the possibility of these experiences as
located in different orders of time and space (divine time
and space) consequent to changes in the level of human
consciousness.[13] The greatest impediment in the study of
psychic experiences has been the subjective nature of these
experiences, which contrasts with the classical objective
nature of science.
Phenomenologically, the visions of the Sufis may be similar
to “psychotic phenomena” like hallucinations (auditory,
visual, etc.) and delusions. The knowledge yielding and the
spiritual nature of these experiences have been questioned
based on this semblance. It has been argued that all kinds
of mystical experiences and hence religious beliefs have
their origin in psychosis with the underlying assumption
that all psychotic phenomena are abnormal. Psychotic
phenomena (hallucinations and delusions) have been shown
to be fairly common in the normal population as well as
during spiritual experiences, which are apparently benign
in nature. It has been argued that all psychotic phenomena
are not abnormal and that abnormality needs to be
redefined.[31] Considering these, there seems to be a need to
examine the spiritual experiences beyond the disease model.
Neurobiology of Sufi experiences
The higher Sufi experiences of annihilation in the ultimate
reality and eternal existence occur rarely but experiences
such as transcendence, tranquility, sense of pleasure, and
detachment occur more frequently. Though there are
no specific neurobiological studies of Sufi experiences, it
seems plausible to extrapolate the findings from studies of
other spiritual experiences, given the similarity between
such experiences. Such experiences have been reported
in certain specific biological states such as near‑death
experiences, temporal lobe epilepsy, psychosis, and
under the influence of drugs.[28] Structural and functional
neuroimaging studies have shown the involvement of
specific neural networks and neurotransmitters with these
experiences. It seems pertinent to mention here that the
elucidation of the underlying biological substrates for
spiritual experiences does not prove or disprove their
authenticity; it merely explains the mechanisms underlying
these experiences. From a more philosophical perspective,
it does, however, suggest a biological determinism and the
unlikely extracorporeal nature of these experiences.[28,32]
Increased religiosity and mystical experiences have been
frequently associated with temporal lobe epilepsy. However,
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positive experiences are extremely uncommonly reported
with temporal lobe epilepsy and many studies have failed
to show any such relationship especially after controlling
for brain damage and psychiatric comorbidity.[28,33,34] The
temporal lobe, more specifically the right, is involved in
emotional synthesis, spatial and time orientation, and strong
emotional experiences, including the elevation of mood.
As the mystical experiences involve modulations of these
neuropsychological functions, mystical experiences have
been attributed more to the right temporal lobe.[28,35] Other
areas of the brain especially the dorso‑lateral prefrontal
cortex and posterior superior parietal lobule have been
associated with preparedness and conscious identification,
and the altered perception of self‑experience during the
spiritual experiences.[36,37]
The neurotransmitters dopamine and serotonin have been
associated with religiosity and spiritual experiences. The
level of religiosity and the positive emotional aspects of
religious and spiritual experiences may be modulated
by dopamine. Self‑transcendence, a trait associated with
spirituality, has been found to be inversely related to 5HT
receptor density. Again, it has been found that psychedelic
drugs like D‑lysergic acid diethylamide and psilocybin having
serotonergic effects lead to spiritual experiences.[38‑40] It
would be interesting to see whether the administration
of drugs with different profiles like antidopaminergics
and antiserotonergics to mystics would abolish such
experiences.
SUFISM AND PSYCHIATRY
The conflict
The term psychiatry is derived from the Greek words
psukhe meaning psyche or soul and iatreia meaning healing;
healing of the psyche or soul. Ironically the relationship
between psychiatry and religion/spirituality has been
a tumultuous one. The relationship has been greatly
influenced by psychoanalysis; Freud considered religion
pathological (neuroticism) and amenable to naturalistic
explanations.[41] The hostile relationship that evolved from
similar such ideas remained till the end of the 20th century
and has given way to the indifference of the 21st century
that it seems psychiatry can ill afford. As Fullford[2] argues,
the conflict between psychiatry and religion/spirituality is
an extension of the more fundamental conflict between
science and religion/spirituality. The incorporation of the
medical model into psychiatry led to its identification
with the empirical sciences based on observation as the
means of knowledge. Religion, on the other hand, is
based on the “revealed” knowledge. As has been argued
earlier in this paper, Sufi experiences share ground with
the prophetic experiences of revelation and may provide
the means to study religion “scientifically.” Sufism can
thus provide the much‑needed bridge between psychiatry
and religion.
Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013
From a clinical perspective, psychiatry deals with the
aspects of human life, which are governed by scientific
facts as well as religious values.[2] Psychiatry by taking into
account both the aspects of human life can develop into
a discipline with a more holistic understanding of human
behavior that can have implications for understanding and
treatment of mental maladies. Psychiatry, thereby, is in
need to shun the indifference and get actively engaged with
the study of religion both from a philosophical and a clinical
perspective.
Clinical encounter
Like other forms of spirituality, Sufism has resurged in the
oriental as well as the occidental world in recent times. Sufi
practices, or a belief in these, form an important part of the
belief system of an increasingly large number of people both
in the Muslim world and outside. The manifold increase in
the mental‑health related problems in recent years,[42] means
that more and more such people will come into contact with
mental‑health related services. The contact of people with
Sufi orientation with the mental health services gives rise to
issues that need to be addressed at multiple levels.
Attitude of the mental health professionals toward patients’
belief systems: Heal thyself
There is evidence to show that a consideration of the spiritual
needs of patients by the mental health professionals confers
benefit to the patients.[43] Unfortunately, there are many
misconceptions about religion and spirituality prevalent
even among the mental health professionals. In a recent
survey, Foskett et al.[44] showed that 45% mental health
professionals felt that religion could lead to mental‑health
related problems. The evidence for this is mixed at the
moment‑studies show positive as well as the negative impact
of the spiritual and religious beliefs and practices on the
physical and mental well‑being of people.[6‑11] Interestingly,
studies have shown that the level of therapeutic satisfaction
of religious individuals varies with the religiosity of the
clinician; being less with the non‑religious ones.[45]
An integral part of the current medical and mental health
training involves inculcating a more objective attitude
in the professionals that implicitly involves keeping their
religious and spiritual beliefs and practices out of the
clinical milieu. Consciously or unconsciously, as D’souza[46]
has pointed out, this objectivity has strayed into keeping
our patients’ religious and spiritual beliefs and needs out
of the therapeutic milieu, thereby, failing the very objective
of medical care – the individual well‑being. This calls for
an effort on the part of mental health professionals to
understand the Sufi beliefs and practices as more and more
such people are likely to come into contact with the mental
health services in increasing geographical locales. However,
due care has to be taken that mental health professionals do
not impose or prescribe their religious or spiritual beliefs to
their patients.
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Assessment of Sufi beliefs and practices: History taking
However, comprehensive a mentally ill patient’s assessment
might be, it most often does not include an assessment of
spiritual beliefs and practices. This is ironical, especially in
the Eastern context, where spiritual including Sufi beliefs
and practices are an integral part of the cultural milieu.
The seeds of this neglect lie mainly in the medical model of
psychiatry that mental health professionals follow and partly
in the lack of training, interest and time and discomfort
with the subject.[44]
Apart from being a set of beliefs and practices, spirituality
including Sufism claims the answers for some fundamental
questions involving the life and death of people, which
assume more significance during the time of illness.[46] It is
not surprising, therefore, that religious and spiritual beliefs
decrease the chances of suicide in mentally ill patients.[47]
Assessment of the religious and spiritual including Sufi
beliefs, therefore, should be a routine in the evaluation of
mentally ill people so that a more patient‑centered plan of
management that invokes the individual patient’s strengths
in the spiritual domain as well is formulated.[48]
The assessment of Sufi beliefs and practices has to be tailored
to the individual patient. The assessment may best be deferred
in an acutely ill patient unless Sufi concerns contribute to
the acute condition. As a routine a brief assessment may be
followed by a more thorough one on a need basis. Several
brief assessment methods have been proposed for the
assessment of spirituality in general that may help screen
the patients for further in‑depth assessment.[49,50] The four
spiritual areas suggested by Koenig and Pritchett[49] to be
screened in any psychiatric evaluation seem to be a good
starting point but need to be modified for assessment of Sufi
beliefs and practices. The initial assessment should include:
1. Faith: Importance of faith in day‑to‑day life? An
increasing number of people from different religious
faiths, besides Islam, are following Sufi beliefs and
practices and hence considerable admixtures of beliefs
and practices should be expected.
2. Influence: Influence of faith on life, past and present?
The Sufi practices of self‑mortification may, apart from
influencing the belief system, lead to significant changes
in the practical life, which needs to be understood in
proper perspective.
3. Community: Affiliations with any religious or spiritual
community? Almost all Sufi believers belong to one or
the other lineage (silsila) which may significantly differ
in terms of beliefs and practices from the other. An
exploration of the lineage would provide a framework
to understand a particular individual’s view point
vis‑à‑vis health and illness.
4. Address: Spiritual needs to be addressed? The Sufi
teacher with whom the given individual has held the
oath of allegiance (bay’a) may need to be incorporated
in the treatment plan to fulfill the spiritual needs.
S220 Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013
An in‑depth interview, from a clinical as well as a spiritual
perspective, may follow this depending upon the needs of
the patient as uncovered during the screening.[51]
Diagnostic considerations
Sufi beliefs and practices can contribute to mental health
as well as illness. The benefits might range from providing
a meaning to life, improved coping, a better quality of
life and mental health, and speedy recovery from mental
illnesses. On the other hand, these beliefs and practices
may sometimes lead to acute breakdowns and may be
causally related to the mental illness or contribute to the
psychopathology.
Nosology
Diagnostic and Statistical Manual of Mental Disorders fourth
Edition‑Text Revision(DSM‑TR)  provides for inclusion of
spiritual and religious factors in two ways for individuals
who do or do not have a mental illness. Religious and
spiritual problems are given a V code under other conditions
that may be a focus of clinical attention. Besides, under the
multiaxial diagnostic system in DSM‑IV‑TR, axis IV describes
psychosocial and environmental factors that may affect the
diagnosis, treatment and prognosis of mental disorders (axis
I and II), where spiritual and religious problems that do not
meet the threshold for a V code can be placed. The religious
and spiritual problems may include conversion to a new
religion (including cults), a rejection of a prior religion or
loss of faith, the intensification of beliefs and practices,
experiences of guilt, mystical experiences, near‑death
experiences, and reactions to terminal illness.[52,53]
Differentiating Sufi experiences from psychotic phenomena
Sufi experiences are diverse and include the domains
of thought, perception, and feeling. Most of these
experiences will never come to the clinical attention for
two reasons: These experiences are firmly grounded in the
spirituo‑cultural milieu from which the person comes, and
there is little in the way of dysfunction that these lead to. Of
the experiences that come to the clinical attention, most can
be differentiated based on the phenomenological grounds.
The content of the experience – spiritual or psychotic, is
culturally determined and may have no bearing on the
diagnosis; it is the form of the experience which differentiates
the two and may reveal the diagnosis. Differentiating the
form from the content of the experience should prevent
such confusions of the past as religious mania.[4] However,
phenomena which resemble psychotic symptoms (delusions
and hallucinations) on phenomenological (form) grounds
do occur during apparently benign spiritual experiences. It
is the differentiation of these experiences that gives rise
to questions about the validity of the concept of mental
illness on one hand and of the spiritual experiences on the
other. Not surprisingly, therefore, extreme views have been
argued about the nature of such experiences – labeling all
of these as psychotic or spiritual depending upon one’s
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Nizamie, et al.: Suism and mental health
leanings. A more balanced view suggests that differentiation
between such phenomenologically similar experiences
may be possible based on their emotional value (spiritual
experiences being mostly positive), overwhelming
nature (spiritual experiences are less overwhelming),
functional deterioration (spiritual experiences are less often
dysfunctional), and as Jackson and Fulford[31] argue, the way
in which the experience in question is embedded in the
individual’s values and beliefs. Again, these differentiations
are value laden and therefore, vary across cultures and are
questionable.
Sufism and psychotherapy
Spiritual and religious beliefs form an important means
of coping with stress for a large number of people but
unfortunately this has received little attention by the
mental health professionals. Recently, however, religion
and spirituality have been incorporated into the therapeutic
process and have shown promising results.[46,54] The
assimilation of spirituality into the psychotherapeutic
processes has been either in the form of an augmentation
of an already existing therapeutic technique – spiritually
augmented cognitive behavior therapy or the development
of new techniques where spirituality itself forms the
core – transpersonal psychotherapy. Though Sufi beliefs
and practices have been incorporated into the transpersonal
psychotherapy but there exists no literature about the
incorporation of these into the cognitive behavior therapy
models.
Spiritually augmented cognitive behavior therapy
Spiritually augmented cognitive behavior therapy is
primarily a cognitive behavior therapy which incorporates
the individual’s belief system, specifically the spiritual,
to focus on the existential issues. The therapist works
with the individual’s spiritual beliefs and practices like
meditation, prayer, etc. but at no point attempts to instill
his own beliefs or beliefs never held by the patient into
the therapeutic process. The therapy spans over 10‑16
sessions, each session lasting 45‑70 min conducted once a
week. The therapy has demonstrated efficacy in controlled
trials with reduction of relapse and re‑hospitalization in
the treatment group.[46] The Sufi themes of patience (sabr),
trust in God (tawwakul), contentment (rida), and God
as the ever‑forgiver may have a significant impact in
changing the negative cognitive schemas and coupled
with the Sufi practices of remembrance of god (zikr) and
thankfulness (shukr) may provide an appropriate framework
for spiritually augmented cognitive behavior therapy for the
Sufi believers.
Transpersonal psychotherapy
Transpersonal psychotherapy is based on the premise that
human beings are essentially spiritual beings and hence
the core qualities associated with spirituality form the
goals of transpersonal psychotherapy.[55] The role of the
Indian J Psychiatry 55: Indian Mental Concepts I – Supplement, January 2013
therapist in transpersonal psychotherapy has been seen
variously as ranging from a spiritual guide to a “fellow
spiritual sojourner.” The therapist does not promote any
specific spiritual philosophy and it is the client who leads
and determines the spiritual content of the therapy.[56]
Different spiritual practices, including Sufism, yoga, qigong,
aikodo have been incorporated into the transpersonal
psychotherapy. Transpersonal psychotherapy has been
used for the treatment of abnormal grief, spiritual
crises, psychotic disorders and substance use disorders.
Transpersonal psychotherapy can provide the basis for
engagement of traditional faith healers with the mental
health care services and given the magnitude of people who
seek traditional faith healers this can have significant public
health impact.[57]
Sufism and mental health care services
A vast number of the mentally ill people in the community
go untreated or seeks the help of spiritual healers in most
of the developing countries. The reasons lie in the belief
systems of the people which foster a spiritually oriented
explanation of the mental illnesses and the practically
non‑existent mental health care services in most of the
rural settings. The large number of mentally ill people
thronging the shrines (dargah) of Sufi saints to seek cure is
a testimony to this. The Erwadi (India) fire at the shrine of
the Sufi saint Shaheed Valiyullah leading to the death of 28
mentally ill people should be a grim reminder of the cost
of neglecting the incorporation of people’s spiritual beliefs
into the mental health care services.[58] The incorporation of
spiritual/Sufi elements into the mental health care services
needs to be a two‑fold process:
1. Incorporation of the spiritual/Sufi healers into the
mental health care delivery system which may include
basic training in identification of mental illnesses and
appropriate referrals when needed.
2. Incorporation of the spiritual/Sufi beliefs and practices
into the therapeutic process which may increase
the utilization of mental health services by a largely
spiritually oriented population.
The integration of spiritual beliefs and practices into the
mental health care delivery system needs efforts both at
the organizational and individual level. Sensitization of the
trainees in the mental health profession to spiritual issues
needs to be given an impetus. The focus of the training
should be on understanding of spirituality as an important
part of the individual seeking help and a thorough
understanding of the belief systems of the people in the
practice area.[43]
CONCLUSION
Sufi beliefs and practices form an integral part of the belief
system of not only the majority of the Muslim world but
also the western world where it is gaining popularity.
S221
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Nizamie, et al.: Suism and mental health
Sufism provides a vital link to the understanding of
revelation – the source of religious knowledge in Islam as
well as other Semitic religions, and influences the mental
health of its believers and practitioners in a significant way.
Unfortunately, there is little in terms of research based
evidence to draw any conclusions in both these directions.
There is a need for research to evolve scientifically sound
means of incorporation of Sufi beliefs and practices into the
mental health care system before any dogmas strike their
roots. At the same time, mental health professionals should
not slide into the role of preachers and start promoting
the Sufi beliefs and practices; the role should rather be
restricted to utilizing these beliefs and practices where it
forms a part of the belief system.
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Source of Support: Nil, Conlict of Interest: None declared

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