Cover Story

A woman comes to Pakistani psychologist Ghazala Rehman complaining of depression, debilitating headaches and conflict with her husband and his parents.

Though the complaint is not unusual by U.S. standards, the treatment that Rehman would likely apply in this case--improved prayer practices and meditation along with a more typical focus on conflict resolution--certainly would be.

Rehman uses this approach with her many Muslim clients who strongly believe in the religion, but are weak at practicing it. And as American interest in Islam escalates in the wake of Sept. 11, it has come to light just how deeply the religion influences nations such as Pakistan--to the point of being integral to every part of life including psychotherapy.

For instance, Rehman, an associate professor of psychology at Quiad-A-Azam University's National Institute of Psychology in Islamabad, advises many of her patients to concentrate harder on the words of the Islamic prayers they often say five times daily, relaxing over them and finding meaning in them.

"The basic principle of Islam is that just as God will never lose hope in humanity, we should never lose hope in our own lives," says Rehman. "Those words are like magic to clients. They feel less lost. They remember that God is listening to us."

A classically trained psychologist, Rehman is quick to point out, however, that she is not "a religious mentor." Rather, she is helping her Muslim clientele spiritually carry out what they already know about their religion, and she is doing this based on Western psychological principles, such as behavior modification.

After all, psychology practice in Pakistan is founded on the Western model: U.S. and European-trained psychologists brought it to the universities in the 1960s, and many Pakistani psychologists continue to be trained in the West. But over the past 10 years, Pakistani psychology practice and research have been increasingly interested in, and shaped by, indigenous culture--one that is largely collectivist, family-oriented and male-led, and one that is 97 percent Islamic.

By recognizing the pervasive influence of religion, "indigenized" psychology helps more clients, say Pakistani psychologists. Even still, their practice is hurt by lingering stigma and suspicions about the field's Western origins, along with a lack of professional regulations and a largely poor, uninsured population. Psychological research is also underdeveloped: Funding is scarce, and only two journals are published there. Nevertheless, psychologists have steadily been gaining a foothold in Pakistan. And many believe that their fellow citizens need their help more than ever as Sept. 11, and the war next door that has followed, provoke growing unrest and anxiety.

The state of practice

A major barrier to getting Pakistanis that help, however, is the stigma that still surrounds psychological treatment, says Mahnazir Riaz, also a psychology professor at Quiad-A-Azam University. Only about 60 clinical psychologists practice professionally in Pakistan--of the 300 psychologists registered with the Pakistan Psychological Association, most focus on university teaching and research. Somewhat disconcerting for those who do practice is a tendency among clients to refuse to park in their driveways for fear of being found out.

"People are afraid of society saying they have some sort of abnormality," says Riaz.

Many women also fear alienating suitors or potential husbands, given that marriage is still the ticket to economic stability for most of them, says Riaz. She notes that if a young woman goes for therapy, "her family will try to keep that confidential within their own house." In fact, says Riaz, many Pakistanis favor the "more acceptable" option of consulting holy people for help.

Psychiatric help is also more acceptable, says psychologist Naushin Rehman, director of the Center for Clinical Psychology at the University of the Punjab in Lahore. Psychiatrists offer the quick, quiet fix of medication, rather than time-consuming talk therapy, she says. Cost is yet another impediment. Few Pakistanis are insured, says Riaz, and since most Pakistani women still do not work outside the home, many women depend on their husbands to permit and pay for treatment.

Also posing difficulties is the fact that certain tenets of Western therapy--such as catharsis and probing one's problems--conflict with Islam. Psychologist Abid Bilal, editor of the Pakistani monthly, Nafsiyat Aur Zindagi (Psychology and Life), points out that "Islam teaches its followers, 'Don't tell anybody about your sins and evil activities, but ask God for forgiveness and then leave it on God.'" Further, many Pakistanis believe that family members claiming to have psychological problems are only "shirking their responsibilities," says Rehman.

Solace in prayer

To overcome such culture clashes, psychology is increasingly accommodating Muslim ideals and Pakistani culture. For example, psychologists take into account their clients' family constraints, particularly the fact that most women live with the husband's family and are beholden to in-laws' wishes, says psychologist Riffat Zaman of the Aga Khan Medical College in Karachi.

She notes that with so few outlets and choices, Pakistani women commonly suffer depression and Somatoform disorders, such as headaches, ulcers, aches and pains. And where Western psychologists might help steer such women toward self-sufficiency, in Pakistan "you mostly help women work as best they can with the marriage they are in," says Zaman.

She favors using a family-systems approach with her clients, focusing on couple and family dynamics and interpersonal skills. The approach also helps men, who often find themselves caught in the crossfire between their wives and parents. In addition, just as other classically trained psychologists do, Zaman uses her clients' religious faith in their treatment.

For example, she once saw a woman with obsessive compulsive disorder who believed she was too unclean to say her prayers, despite the fact that regular prayer had once helped her. Zaman urged the woman to pray again. If clients have pressing religious concerns, however, Zaman refers them to religious healers, "since that is not my training."

Some Pakistani psychologists believe, however, that religious healing ought to be part of practitioners' training. Most notably, Syed Azhar Ali Rizvi, a founder of the Society for the Advancement of Muslim Psychology, has pioneered training in Islamic counseling at the Institute of Muslim Psychology at Al-Khair University in Lahore. Trainees learn to assign religious readings to clients and help them "fight negative thinking that leads to abnormality," says Rizvi, the institute's director.

In academe

Due to Rizvi's influence, nine of Pakistan's 16 postgraduate psychology departments require students to take at least one course in Muslim psychology. And, even though Pakistani psychologists use Western research methodology, they increasingly study issues and problems specific to their own culture. For example, Riaz researches the academic and emotional development of children born into polygamy, a fairly common practice in Pakistan.

Just as with practice, however, there are notable barriers to Pakistani research. Little government funding goes to research, which means universities focus more on teaching, says Naeem Tariq, editor-in-chief of the Pakistan Journal of Psychological Research. He notes that he finds it difficult to keep the journal going because he gets so few high-quality, solid empirical studies.

On the brighter side, psychology has gained increasing respect relative to psychiatry over the past 20 years, says Naushin Rehman. More psychologists hold top jobs in such areas as drug addiction and rehabilitation of schizophrenics, she says. What's more, her base--Punjab University's Center for Clinical Psychology--has set up a popular hotline for Pakistani citizens anxious over Sept. 11 and the ensuing war. "We are all feeling sensitive, sad and angry," says Rehman. And in her view, that makes psychology more relevant to the populace than ever.

PAKISTAN

Population: 144,616,639

Religions: Muslim 97 percent, Christian, Hindu and other 3 percent.

Languages: Urdu (national), 8 percent; Punjabi, 48 percent; Sindhi, 12 percent; English, Burushaski and other, 32 percent.

Literate: 42.7 percent.

Further Reading

Sources: Central Intelligence Agency, U.S. State Department.