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transcultural
psychiatry
March
2002
ARTICLE

ReligiousCultural Psychotherapy in the

Management of Anxiety Patients
SALLEH MOHD. RAZALI, KASSIM AMINAH, & UMEED ALI KHAN
Universiti Sains Malaysia
Abstract This study investigated the effectiveness of incorporating sociocultural and religious aspects in the management of anxiety among Muslim
patients of ethnic Malay origin. Eighty-five religious and 80 non-religious
patients with generalized anxiety disorder (GAD) were randomly assigned
to the study or control group. Both groups received a standard treatment for
GAD, although the study group received additional religiouscultural
psychotherapy (RCP). Patients were followed up and assessed periodically
for six months. Religious patients receiving RCP showed significantly more
rapid improvement in anxiety symptoms than those in the control group.
The difference, however, became non-significant at the end of six months.
There was no significant difference in improvement between the study and
control group of non-religious patients. We concluded that RCP rapidly
improved anxiety symptoms in Muslim patients with a strong religious
background.
Key words anxiety culture Muslim psychotherapy religion

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]
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introduction of a sub-category under the V codes in the DSM-IV

(American Psychiatric Association [APA], 1994) known as religious and
spiritual problem (V 62.89). It suggests that psychiatrists should consider
not only the physical, psychological and socio-cultural, but also the
religious (spiritual) aspects of their patients lives.
Religious issues in psychotherapy have been examined in several studies
(Galanter, Lurson, & Rubenstone, 1991; Sordas 1990). Galanter and
colleagues (1991), for example, described the impact of Christian
psychiatry, a broad-based national movement of psychiatrists who are
evangelical Christians. Recently, Azhar and Varma (1994, 1995) have
demonstrated the effectiveness of religious psychotherapy in anxiety and
depressive Muslim patients. However, there have been no controlled
studies to compare the relative efficacy of religiously oriented psychotherapy for religious and non-religious patients.
The aim of this study was to investigate the effectiveness of incorporating cultural and religious (spiritual) themes into the psychotherapy of
generalized anxiety disorder (GAD) among Malay patients with different
religious backgrounds. The psychotherapeutic intervention in this study
has a wider scope than the previous studies (Azhar & Varma, 1994, 1995)
because it incorporated both socio-cultural and religious dimensions.
Because the therapists were brought up in the same culture as the patients,
they could easily incorporate relevant religious and socio-cultural factors
into the psychotherapeutic process. Western concepts have limited value
for these patients because most of them are not psychologically minded
but culturally and religiously oriented. In Malaysia, this is not a new
phenomenon because traditional healers (bomohs) have been incorporating religioussocio-cultural aspects in the treatment of neurotic patients
with great success (Razali, 1989). In view of the popularity of bomohs, the
first author had suggested greater cooperation between psychiatrists and
bomohs so that it would be easier for patients and their families to make a
wise decision about the most suitable form of treatment to seek (Razali,
1995).

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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Hamilton Anxiety Rating Scale (HARS; Bech, Kastrup, Rafaelsen, 1986) by

an independent psychiatrist (UAK) who was blind to the patients group
and treatment modality at the start of treatment. Their progress was then
evaluated at the fourth, twelfth and twenty-sixth week. The inter-rater
reliability between the therapists using the research tools was good (Kappa
coefficient greater than .80). Religiosity was assessed by a Malay version of
a validated religious questionnaire especially designed for Muslims. It
assessed five dimensions in the religious domain (Ahmad, 1980, 1999;
Robert, 1982): five pillars of Islam, six principles of Islamic faith, obedience and honest servant of God, supreme power of God (the creation) and
Islamic way of life. Patients had to answer positively (based on a standard
key) in all five sections of the questionnaire to be classified as religious.
The university research and ethics committee approved the study. All the
selected patients gave written consent after the research psychiatrists
explained the procedures of the study to them. They were divided equally
into two main groups, religious and non-religious. Patients in both groups
received a standard treatment for GAD. They were treated by the research
psychiatrists using benzodiazepines for not more than six weeks, supportive psychotherapy (reassurance, improving coping mechanism and
reinforcing adaptive behaviour) and/or a simple relaxation exercise
according to the clinicians assessment.
In addition, the study group received religiouscultural psychotherapy
(RCP). The therapists had mastered basic skills of cognitive therapy and
had a fundamental Islamic knowledge that enabled them to use the Holy
Koran and Hadith (sayings and customs of the prophet) as guidance. The
technique of psychotherapy was similar to the cognitive model of Beck and
colleagues (Beck, Rush, Show, & Emery, 1979). We first identified a faulty
negative thought and modified it using cognitive techniques guided by the
Koran and Hadith. We then examined evidence for and against the
distorted automatic thoughts and substituted them with religious-oriented
interpretations. Identifying the basic schemata or beliefs that led the
patient to process information in idiosyncratic ways typically occurred
later in the therapy. Lastly, we discussed religious issues related to the illness
and taught patients effective coping skills from an Islamic perspective.
Cultural beliefs about the illness were also discussed to strengthen the
therapeutic relationship. We avoided giving lectures, preaching or
imposing values on our patients. A therapist who has this tendency is not
suitable to carry out this religious form of therapy. The general guidelines
for the psychotherapy were as follows:
1.

Encouraging patients to be close to Allah s.w.t. (Almighty and

Glorious is He) pray regularly, read the Holy Koran and zikr
(commemoration of Allahs name).
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2.
3.
4.
5.

Advising patients to change their lifestyle to follow the custom of the

prophet s.a.w. (Allah bless him and give him peace).
Acceptance of patients interpretation of symptoms.
Discussion of the aetiology of the illness from a cultural perspective
(appropriate to social class and educational background).
Avoidance of preaching or opposing the patients view.

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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Transcultural Psychiatry 39(1)

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).

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SALLEH MOHD. RAZALI, MD, is Associate Professor and Head of the Department of
Psychiatry, School of Medical Sciences, Universiti Sains Malaysia. He subspecializes in social and community psychiatry and his research interests include crosscultural psychiatry. Address: Department of Psychiatry, School of Medical
Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
[E-mail: mrazali@kb.usm.my]
KASSIM AMINAH, MD, is a psychiatrist for the Ministry of Health, Malaysia, at Hospital Kuala Lumpur. A dedicated Muslim, she is interested in psychotherapy and
counselling.
UMEED ALI KHAN, MD, is attached to the Faculty of Medicine, International Islamic
University of Malaysia. His research interests include anxiety and mood disorders.

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