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.......................................................................................................................................... 3 Spiritual or Religious Aspects in Case Conceptualization ............................................................. 6 What Islam and Muslim Mean ...................................................................................................... 12 Servanthood and Healing through Prayers ............................................................................... 16 Ablution and Prescribed Prayers ............................................................................................... 18 Physical and Mindfulness Exercises and Prayers ..................................................................... 20 Perceptions of Illness and Healing for Muslims ........................................................................... 21 What to Do ................................................................................................................................ 24 Acceptance and Commitment Therapy (ACT) ............................................................................. 25 How and Why ACT might be a more Appropriate Approach for Muslim Clients ...................... 30 Six Core Processes and their implementation in Muslims’ Life .................................................. 34 Flexible Attention to the Present Moment ................................................................................ 35 Self-as-Context (Perspective Taking) ....................................................................................... 38 Defusion .................................................................................................................................... 39 Acceptance ................................................................................................................................ 40 Connecting with Values ............................................................................................................ 42 Committed Action ..................................................................................................................... 43 Case Studies .................................................................................................................................. 44 SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 2 First Case Study from a Correctional Facility .......................................................................... 45 Second Case Study from a Community Center ........................................................................ 52 Conclusion .................................................................................................................................... 61 References ..................................................................................................................................... 63 Appendix ....................................................................................................................................... 67 The Guest House ....................................................................................................................... 67 SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 3 Abstract The Muslim population is increasing in the U.S., yet this population has been marginalized due to three main factors: Misinformation or disinformation by the media, the lack of factual understanding regarding Islamic spiritual and religious practice on the part of counseling professionals, and the acts of a very small number of radicals. Thus Muslims avoid being assertive in seeking and staying in counseling due to overt and unintentional discrimination. It is the counseling profession's responsibility to extent its knowledge base and understanding about the issues and concerns of the Muslim community, including the religious and spiritual tenets of Islam. The author has three main goals in this paper. The first one is to cultivate awareness of multicultural and spiritual aspects and their role in the counseling process for Muslim clients. The next one is to enumerate particular tenets of Islam to increase awareness of Muslim spiritual practices and to provide a basic framework for understanding Islam, thus enabling counselors to be culturally and religiously sensitive with their Muslim clients. The final goal of this thesis is to explain the basics of Acceptance and Commitment Therapy (ACT) and how it is congruent and effective with the tenets of Islam. It provides this information through a literature review and with two Muslim case studies from a spiritual strength and ACT perspective, thus enabling the reader to provide cultural/religious sensitive counseling services to Muslim clients.The Muslim population is increasing in the U.S., yet this population has been marginalized due to three main factors: Misinformation or disinformation by the media, the lack of factual understanding regarding Islamic spiritual and religious practice on the part of counseling professionals, and the acts of a very small number of radicals. Thus Muslims avoid being assertive in seeking and staying in counseling due to overt and unintentional discrimination. It is the counseling profession's responsibility to extent its knowledge base and understanding about the issues and concerns of the Muslim community, including the religious and spiritual tenets of Islam. The author has three main goals in this paper. The first one is to cultivate awareness of multicultural and spiritual aspects and their role in the counseling process for Muslim clients. The next one is to enumerate particular tenets of Islam to increase awareness of Muslim spiritual practices and to provide a basic framework for understanding Islam, thus enabling counselors to be culturally and religiously sensitive with their Muslim clients. The final goal of this thesis is to explain the basics of Acceptance and Commitment Therapy (ACT) and how it is congruent and effective with the tenets of Islam. It provides this information through a literature review and with two Muslim case studies from a spiritual strength and ACT perspective, thus enabling the reader to provide cultural/religious sensitive counseling services to Muslim clients. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 4 Spiritual Strength: The use of Acceptance and Commitment Therapy (ACT) with Muslim Clients Culture has an important role in individuals’ lives, and increasing our awareness of our clients’ cultures enables us to better understand their issues and their expectations of their treatment process (Padela, Killawi, Forman, DeMonner, & Heisler, 2012). Padela et al. (2012) express that religious beliefs, practices, and values are vitally important and are primary factors of the treatment process for numerous cultural groups; they include American Muslims as being one of these groups. The Muslim population in the US is estimated to be 2.75 million which is 0.8% of the population making it the third largest religious group in the United States (Pew Forum, 2011); however, the Council on American-Islamic Relations (CAIR) estimates the number of Muslims to be seven million (2012). All population data indicates that the number of Muslims in the Western countries is increasing; therefore, understanding this group is becoming more important. Roysircar (2003) has expressed that awareness of cross-cultural and multicultural counseling sensitivity has improved; however, Muslim Americans and immigrant Muslims are still widely misunderstood. Exclusion and harassment toward Muslims in the United States have increased significantly since 9/11, to the point that many Muslim Americans have changed aspects of their cultural and religious life styles. These changes include: Muslim women no longer wearing their hijabs in public, Muslims avoiding cultural activities and community functions, and Muslims refraining from attending religious services at the local mosques just to avoid overt discrimination (Inayat, 2002). Chaudhry and Li (2011) point out that Muslims are more likely to have mental health issues than other minority groups. Unfortunately, Muslims tend not to seek help from mental health providers (Padela et al., 2012; McAulife, 2013); if they do, they tend not SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 5 to continue because their counselors often have a lack of understanding of the role of their faith in their life. For example, a male Muslim college student asked the author to help him for his lack of motivation, academic success, and attention. The student had a belief that the main reason behind his issues was sorcery/witchcraft. The author recommended him to visit the university counseling center. The student responded with a moderate negative attitude and expressed that he was unwilling to see a counselor for this issues. However, he later did choose to visit the counseling center to get help for his issues. The center, after the first session, referred him to a psychiatrist, and the psychiatrist prescribed antidepressant medication – no one even attempted to address the role of his belief and sorcery within the Muslim tradition. Later, the student expressed to the author how the counselor and psychiatrist assumed he has some delusions or hallucinations. The student reported that they were unhelpful and untrustworthy because he was concerned that such information would go on his record. He stopped seeking counseling and taking prescribed medication after a short time and sought some other traditional solutions, such as visiting a sheikh, to come over his difficulties. Another example is a male Muslim international graduate student who could not pay attention in his classes. He felt bad about this and asked the author to help him since the student was a friend of the author. The author listened to him, provided enough information and recommended him to visit the university counseling center. The student showed an extreme negative response to that suggestion. He become very sad, saying he was not crazy and asking what the author meant by suggesting a counselor. He asked the author whether something was wrong with him. However, three weeks later, the student told the author that he had visited the counseling center and found it extremely helpful. He reported that the counselor listened to him, was curious about his culture and how it was for him in his back country, and also referred him to psychiatrist for Adult Attention Deficit SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 6 Disorder (ADD). He ended up getting a diagnosis for ADD. The important thing to note is that the way the counselor and psychiatrist addressed the issue helped him accept the treatment. He said that he came to know himself much better; ADD became a part of him, he said. The student then continued seeing his counselor for seven sessions. These two brief examples show how the students initially had a negative attitude – in other words, stigma – toward seeking counseling, but also how both of them later on visited the counseling centers. The way the counselors and other health providers treated them played a crucial role in either repelling or retaining them as clients. Spiritual or Religious Aspects in Case Conceptualization It is important to understand clients from a biopsychosocial perspective that will provide an integral picture of clients in order to understand what is going on with them and then what kinds of interventions could be implemented. However, research by Cashwell and others (2013) shows many counselors and counseling settings do not pay enough attention to spiritual/religious aspect of clients in initial interviews, case conceptualization, and counseling sessions (Cashwell et al., 2013). They conducted a study that consisted of 30 items to see how counselors rank the importance of spiritual/religious aspects and how much they integrate these aspects in their sessions. The result showed there was a disparity, for almost all 30 items, between how they rank the importance of spiritual/religious aspects for clients and how often those counselors integrate these aspects in counseling process. While the participant counselors have ranked the importance of these aspects high, they stated that they do not pay attention to spiritual or religious aspects as much as they see these aspects important. One of the main themes of the study was that counselors tended not to explicitly address these aspects. The authors also explained how explicitly addressing the way clients perceive both their spiritual and religious aspects might SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 7 strengthen the therapeutic relationship. The authors asked the important question of how these counselors are able to come with a holistic case conceptualization while they rank spirituality/religiosity as important aspects but listen less frequently for spiritual/religious themes and do not actively use informal and formal assessments to understand the role of these in clients’ life. The authors stated the importance of understanding this gap or inconsistency and coming up with clinical interventions to promote the utilization of spiritual and religious aspects of clients. The authors also reported that some of the counselors might be hostile to religions concepts; therefore, how could they be able to work with highly spiritual/religious clients? It is important to be aware that Muslims in general do not make a separation or differentiation between spirituality and religiosity and neither a separation between their daily life and their belief. Muslims see spirituality, religion, and daily life as a single integrated concept instead of different concepts. Another important point is that most of the Muslims will not identify themselves as religious; though, their belief is embedded into their lives and they pay utmost attention to practice their religion throughout their days. Considering all of the above mentioned reasons that Cashwell et al. (2013) stated is important because Islam has an important effect on most Muslims, and some Muslim clients (whether they express this explicitly or implicitly) will want to use their belief system to get over their issues. The author of this thesis explains, later in the paper, how the two Muslim clients held a strong belief and were trying to put it into practice in their daily life and also in the counseling sessions. In order to explain how not addressing spiritual/religious issues might be counterproductive, the author of this paper states one of his experiences with his tape supervisor and site supervisor while he was doing his practicum at a county correctional facility. The author was conducting a process group in the correctional facility and had an African American male SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 8 client who would just sit in the group and would not say anything, as if in protest against the group. The client kept being silent for two weeks, but within the third week the client learned that the author is Muslim. This occurred when the author had to pray in the jail and asked his site supervisor if he knew the direction for prayer. Muslims turn to Mecca while praying their daily prayers (salah, in Arabic, as they are commonly called), and the author had to ask someone to help him learn the direction since nobody was allowed to use any electronic equipment inside the facility. The site supervisor first told the author to just sit or stand at a corner and use a chair to pray. The site supervisor did not know anything about how Muslims pray, and then he said he did not know the direction and said that he knew a Muslim client. He called the African American client who was silent in the group. The site supervisor and the author asked him for the direction and the Muslim client showed a clearly wrong direction. However, the author/counselor was able to learn that his African American client was Muslim. The client later approached the author/counselor and said that he was Muslim and wanted to learn more about Islam and asked whether the counselor could teach him about Islam. The counselor talked to his site supervisor about this request and provided more information about the client, and the counselor started to provide individual counseling to the client. Through the individual and group counseling sessions, the author learned that the client had converted to Islam in the jail. The client reported that he had asked the site supervisor to provide Islamic services or a Muslim chaplain since there were some other religious chaplains and services in the jail; however, the client did not get any positive response from the site supervisor and felt angry toward counseling services and therefore took on a quiet/protesting attitude. The site supervisor was always busy because much was going on and he therefore did not have enough time to pay attention to this particular client. The author also realized that the site supervisor did not know the basics of Islam besides SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 9 knowing that it is a religion, has a book, and its believers pray. The author continued seeing the client both in individual and groups counseling, and the client became much more willing to talk about himself. The client was interested in how he could increase his knowledge of his belief and practice it in his life. The author elaborates on this case further in the case studies section later in this paper. The important point to note with regards to this section is that the site supervisor, after a few sessions, told to the counselor that “the client is now open and engaged, that was/is good to use his belief to involve him; however, it is now more appropriate to start talking less about religion and focus on clinical work” (personal communication, February 12, 2013). The tape supervisor of the counselor also expressed almost the same thing after she had attended two sessions for live supervision. The tape supervisor suggested having two sessions with the client, the agenda of the first being discussion about Islam and the agenda of the second being about clinical work rather than about Islam. Based on that idea, the counselor began providing two individual counseling sessions, the first one in the morning and the other in the afternoon. In the first one the author/counselor would provided space for the client to talk about his belief since the client strongly would want to learn and practice his belief in his life. As for the second session, the counselor and the client would focus on other issues besides his belief. The author found this clear separation helpful because he also found that it was difficult to work with such a client. From time to time the author struggled with identifying his role, trying to consolidate between whether he was a counselor or a kind of teacher who was helping the client increase his knowledge. However, after a few sessions the counselor did not find the two-session format helpful because it was not possible for this client to separate sessions and topics. From this experience the author realized how his site and tape supervisors did not even have basic knowledge of Islam and how they were not aware of how Islam is embedded in the daily life of a SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 10 Muslim. This experience supports what Cashwell et al. (2013) found and stressed in their study regarding the importance of paying attention to spiritual/religious issues and addressing them throughout the counseling process. It is critical to pay attention to how counselors and other health care providers perceive Islam and their Muslim clients and increase their knowledge regarding this topic when they come across Muslim clients. Another important and positive experience regarding spiritual/religious aspects with Muslim clients happened while the author was performing his internship at another setting that is a comprehensive health care, counseling, social work, referral, as well as educational and recreational services facility. The author started to provide counseling to a Muslim college female student who was trying to practice her religion and gave great value to this aspect of her life. The author asked his site supervisor how he could work with her and whether he could and should invest time in spiritual/religious issues and topics if she brought them up. The site supervisor stated that he does not know a lot about Islam, but it is certainly necessary to address spiritual/religious issues when the clients bring them up. The site supervisor also shared the study of Assay and Lambert (1999) to show how it is important to pay attention to other client factors, not just sessions, to create wellness. The initial interview case conceptualization form at the setting also included a few questions regarding spiritual/religious aspects. The counselor worked with this client for nearly a year and addressed spiritual/religious aspects from time to time since they had central effects on the client’s life. The author also elaborates this case later in this paper. This experience, like the first case mentioned above, shows how it is crucial to be sensitive to spiritual/religious aspects while working with Muslim clients and especially with Muslim clients who try to practice their beliefs and prefer to identify themselves as Muslim in SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 11 social life. This case also shows how counselor educators need to be careful to provide the best supervision regarding spiritual/religious issues. Padela et al. (2012) conducted a study in Michigan to explore Muslim perceptions on healing. They found out that Muslims’ belief has a central role in the healing process, both directly through recitation of the Qur’an and supplication and indirectly through human agents (e.g., imams, health care providers, family, friends, and community). Studies also stress the importance of understanding Muslim clients’ spirituality/religion and also not to stereotype them with the community they live in (Williams, 2005; Ibrahim & Dykeman, 2011). Ibrahim and Dykeman (2011) suggest that a cultural, spiritual/religious, worldview, and acculturation assessment could make working with Muslim clients easier and more productive. The key factors are how Muslims see their belief system as a resource to get over both physical and psychological issues and to what degree counselors are aware of that and integrate it into the treatment. These studies indicate that counselors and other health providers have a responsibility to increase their awareness, sensitivity, knowledge of Muslims, and skills to integrate their beliefs into treatment process. Likewise, it is crucial to find therapeutic approaches and other interventions that correspond with Islamic belief systems to assist Muslim clients in utilizing their faith and religion as a strength. The author argues that Acceptance and Commitment Therapy and numerous aspects of Islam match at a foundational level. Therefore, utilizing ACT with Muslim clients provides cultural and spiritual sensitivity that will increase the efficacy of the counseling process and improve the therapeutic relationship. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 12 What Islam and Muslim Mean Based on the studies discussed above, it is necessary for counselors to have basic knowledge of Islam and its components. The word “Islam” is Arabic and comes from the root word “silm,” which means “peace” and “submission”. Therefore, Islam means submission or surrender of one’s will to Allah (God); anyone who does so is identified as a Muslim. One of the important points to understand is that Islam is not a new religion rather it is the last revelation from the Divine. According to Islam, Prophet Adam is the first prophet and Prophet Muhammad is the last one, and the Qur’an (holy book) is the last Holy Book from Allah Therefore, the religion/message of Prophet Adam, Noah, Abraham, Jacob, Solomon, David, Moses, Jesus, and all other prophets is Islam as it has been mentioned in Qur’an many times, and these prophets are Muslim. This is an important point because non-Muslims are not aware of the fact that Muslims accept all of these prophets and divine messages that have been sent to them through miracles and Holy books like the Psalms, Torah, and Bible. It is important to know these pieces of information because these all have an important place in Muslims’ lives, and having respect for and belief in all of them is a requirement in order to be Muslim. However, it is also crucial to know that Muslims believe that the messages that had been sent to previous prophets, with the exception of the final prophet, Prophet Muhammad, had been changed by people through history. According to Muslims, the final message, the Qur’an, will not be changed since God has stated that he will reserve it until the last day. In order to provide a brief and clear summary to make it easy to understand the foundations of Islam, it might be useful to look at the following table and brief descriptions of each concept. This thesis might seem too detailed in its information about Islam, but the rationale SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 13 and need behind this might become clearer once one learns how Islam affects Muslim clients’ daily lives and how much counselors and other health providers are lacking this knowledge. Table 1 Foundations of Islam Primary Sources Quran Sunnah Five pillars of Islam 1. Declaration of Faith (Shahada) 2. Prayer (Salah) 3. Obligatory Charity (Zakah) 4. Fasting (Sawm) 5. Pilgrimage (Hajj) Faith in six principles 1. Allah 2. Allah’s angels 3. Allah’s books 4. Allah’s prophets 5. The Hereafter 6. The Divine Decree and Destiny Secondary Sources Ijma Qiyas (or aql) The Qur’an is the last holy book according to Islam. The word, Qur’an, literally means “the recitation.” It is the main and primary resource for Islam. The Qur’an was revealed to Prophet Muhammad in 610 AD in Mecca. It consists of 114 chapters and 6236 verses; though, some scholars may come with a little different number of verses since they count in a different way. In the original language of the Qur’an is Arabic, and Muslims recite it in Arabic in their SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 14 prayers. The first verses revealed to Prophet Muhammad are "Read, in the name of your Lord who created (1) Created man from a clinging substance (2). Read, and your Lord is the Most Generous (3) Who taught by the pen (4) Taught man, what they knew not" (Qur’an 96:1-5). It is important to know these verses because they are very important to Muslims, stressing the importance of reading. However, the chapter of these verses is not the first chapter in the Qur’an when one opens it. The first chapter in the Qur’an is Al-Fatiha – in English, The Opening – because this chapter is the first that was revealed at one time as a whole, and Muslims read this chapter at least 17 times a day in their daily prayer. The chapter is very important for Muslims since it carries many key messages, though it is very short. It consists of seven verses, the first being “ In the name of Allah, the Entirely Merciful, the Especially Merciful” (Quran, 1:1). It is important to know Muslims view reciting and understanding Qur’an as a direct way to receive healing from Allah (Padela et al., 2012), and this is mentioned in Qur’an many times. “Quran is the essential core of Islam and the source of doctrine, law, knowledge, and spiritual experiences of Muslims across the globe” (Hedayat-Diba, 2000, p. 291). The second primary resource is the Sunnah, which is the saying and actions of Prophet Muhammad. The Sunnah is the second primary source after Qur’an, and it has a crucial role for Muslims. Secondary sources are Ijma and Qiyas (some sects of Islam may name Qiyas as Aql). The former means the consensus of qualified scholars who possess the wisdom and knowledge to derive Islamic rule from Quran and Sunnah. The latter one means to derive a solution for something, which is not clearly established in the Quran and the Sunnah, by means of an established rule that shares a commonality. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 15 As shown in the table, the five pillars of Islam are: The declaration of Faith (Shada), prescribed prayers (salah), obligatory charity (zakah), fasting (sawm), and (if a Muslim can afford to go) pilgrimage (hajj). It could be very helpful to briefly look at each of them and how they affect the Muslims’ lives. Declaration of Faith (shahada) is the first pillar of Islam, and it is acknowledging that there is no diety worthy of worship except Allah and that Prophet Muhammad is His servant and messenger. This pillar is so comprehensive that it includes the six Faith principles including faith in Allah, Allah’s angels, Allah’s books, Allah’s Prophets, the hereafter, and the divine decree and destiny. The second pillar of Islam is the prescribed prayer (salah). Muslims have to practice these prescribed prayers five times a day. In addition to that, Muslim males have to pray Friday Prayer with the congregation. This concept will be elaborated on further later in this paper because of its important role in Muslims’ lives. The next pillar of Islam is Purification of Wealth (Zakah), which is giving of alms (2.5% of one’s wealth) to needy people if one has sufficient wealth. Islamic law explains what constitutes sufficient wealth. The fourth pillar is fasting (sawm), which is to abstain from food, drink, sexual activity, and bad actions (such as lying, insulting, etc) from dawn to sunset during the month of Ramadan, the ninth month of the Islamic lunar calendar. The last pillar is pilgrimage (hajj) to Mecca at least once in a lifetime if one can afford it. It is important to have this basic knowledge of the pillars of Islam and more importantly how they are embedded in the daily lives of Muslims who practice their religion. It would be a SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 16 mistake to assume that Muslims’ beliefs are something that is practiced once a week, month, or a year; it is practiced throughout each and every day. Servanthood and Healing through Prayers Servanthood is an important concept in Islam and it is repeated hundreds of times in Qur’an and Sunnah. In Islam, any good intentions and actions are counted as prayer and good deeds, as the verses stress it many times throughout Qur’an. However, daily prayers, known as salah, are obligatory and have a specific place in the belief. “So whoever does an atom's weight of good will see it...and establish prayer... O you who have believed, seek help through patience and prayer... ” (Qur’an, 99:7; 2:110; 2:153). Prescribed daily prayers have an important place in Islam, as this is the second pillar after the declaration of faith. Therefore, it is important to be aware of how Muslims practice daily prayers throughout the day so that counselors can acknowledge and facilitate this aspect in their clients. The author of this paper has come across many counselors in training, counselors, site supervisors, and counselor educators who assumed that the prescribed prayer of Muslims was similar to that of Jews and Christians. They found it difficult to understand until they learned more. Considering this, it might be useful to look at the prescribed prayers in detail and see how they play an important function in the lives of Muslims. There are five prescribed daily prayers, and each Muslim is required to perform them during their appointed times. In order to pray, Muslims must first have their bodies clean to certain standard legislated by Islam for prayer; they must be in a state of ritual purity. A main prerequisite of this is that they must clean their genital areas with water after they use the restroom. Hence, it is necessary to provide watering cans, as you can see from the following picture, in restrooms when one has Muslim clients. It is also important to note that though cleaning with water is a requirement for Muslims, many non-Muslim people from the Middle SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 17 East and some other cultures use water in restrooms to clean their genital areas after using the restroom. Therefore, the multicultural part of this concept is also important, and providing water by watering cans or otherwise will better the relationship of Muslim clients to the setting and counselor since this is a sign of respect and consideration. For example, the author expressed this need for his Muslim female client at his internship setting, and the setting provided the watering can. The Muslim female client provided positive feedback as soon as she saw the setting had provided the watering cans in the restrooms. The setting did not only provide watering cans for the restrooms in the counseling department but also in some other departments as well since they had some Muslim patients at other departments. The author himself also found this consideration very helpful since he also practices his belief. Such consideration and actions might create or increase the positive attitude of Muslim clients, influencing them to stay in counseling. The author conducted a semi-formal survey among Muslim students at the University of Rochester to see how many Muslim college students viewed not having watering cans as a main issue for them. The result showed over 90% of the students reported that it has been a serious issue for them, and not having watering cans in the restrooms has been affecting them in a very negative way. Based on this research, the author with some other students through Graduate and Undergraduate Muslim Student Associations at his university expressed the issue to officials and the interfaith chapel, University Health Center, and a few other departments in the university. The institutions, though some were resistant and made a big deal out of this, put some watering cans in the restrooms to make life easier for their Muslim students. The students’ feedback was very positive following this improvement. Considering all of these, providing watering cans in the restrooms either by providing watering cans or providing water through some other more systematic ways, which could be discussed with architects and engineers as both ways have been SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 18 used in Muslim countries, such as Turkey, at counseling settings might be very helpful to build and improve the therapeutic relationship and trust between counselor and Muslim client and to cultivate a positive attitude toward seeking counseling. Figure 1: Watering can to put in the restroom Ablution and Prescribed Prayers After the body is clean from impurities, a Muslim needs to take ablution (wudoo) to reach ritual purity. This means washing hands, face, arms, partially wetting the head, and washing the feet; in this order. It is important to keep in mind that many Muslims see ablution as a way to relax since Prophet Muhammad has recommended Muslims to perform ablution when they feel angry or distressed. Therefore, it might be useful to keep this in mind and suggest or remind this to Muslim clients as a technique. The two Muslim clients in the case example stated that taking ablution for prayers was very helpful to them. After taking ablution, a Muslim can pray. There are five daily prescribed prayers (salah) including morning (Fajr), noon (Dhuhr), afternoon (Asr), evening (Maghrib), and late evening (Isha). Muslims turn toward the Kaaba in Mecca when they pray these prayers. The prayers consist of different body postures including standing, bowing and prostrating, as shown in the following picture. Another important point to note is that the time for each prayer changes slightly each day since it depends on the timing of the sun’s positions, which changes throughout the year. It is also necessary to know this so that one can better facilitate life for Muslim clients SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 19 when necessary. For example, the Muslim female client reported that some professors would lecture for two to three hours straight with no breaks, and that she had to leave the class each time to go pray. She would get disturbed due to missing content when leaving the class for five to ten minutes each time. The author of this paper also had the same issue with his classes and talked to his professors. Some of them arranged a break accordingly so he could pray during the break. The author of this paper conducted a semi-formal survey and asked 30 Muslim students if they also have the same issue; 22 of them reported they pray daily and have had this difficulty every day they have had classes. Therefore, understanding how prayer times change daily and getting in touch with Muslim students to make appropriate changes is crucial. One may understand prayers and how times change from the following table. Table 2 Time for prescribed prayers change almost every day May 2014 Fajr (I) Sunrise Dhuhr (II) Asr (III) Magrib (IV) Isha (V) 2 4:31 6:02 1:08 5:03 8:13 9:44 15 4:10 5:46 1:07 5:07 8:28 10:05 31 3:50 5:34 1:09 5:12 8:43 10:27 How many rakats/units of prayer a day 2 Fard (obligatory) + 2 Sunnah (optional) 4 op. + 4 ob. + 2 optional 4 op. + 4 ob. 3 ob. + 4 op. 4 op. + 4 ob. + 5op. In a day total: obligatory 17 & optional 25 = 52 rakats/actions Time for Rochester, NY SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 20 Figure 2: Performing ablution Physical and Mindfulness Exercises and Prayers After the prayers, there are some optional rituals that Prophet Muhammad has recommended. Ablution, prayers, and rituals such as supplication carry some aspects of physical and mindfulness exercises. Therefore, it is important for a counselor to be aware of and acknowledging ablution, prayer, and rituals. Ivey and Ivey state in one of the American Counseling Association podcasts that one of the previous American Psychiatrist Association (APA) presidents would say that it is unethical if a psychiatrist prescribes medication but not physical exercises (ACA, 2010). The importance of daily physical exercises is becoming more central to the practice of counseling. Besides that, mindfulness exercises are also receiving more attention in counseling research. The research body that supports physical and mindfulness exercises is paramount. Therefore, it is important to consider these aspects since Muslims who practice their religion are practicing a lot of both physical and mindfulness exercises throughout the day, which is very important in terms of continuity to get the utmost benefit. From the following picture one can see how one rakat (unit of prayer) is practiced during prescribed SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 21 prayer, and Muslims who practice daily-prescribed prayers practice this action at least 17 times (obligatory ones) throughout the day. Many Muslims practice this action 52 times (optional) throughout the day. Being aware of such physical and mindful exercises and acknowledging these, if a Muslim client performs daily prayers, with Muslim clients might be productive so that they might be empowered and encouraged. Figure 3: A rakat (unit) in prayer Perceptions of Illness and Healing for Muslims It is important to pay attention to how Muslim clients explain illness and healing. According to Islam and its primary resources, Allah (God) is the one who controls both health and illness and God is the ultimate doctor (Padela et al., 2012). There are many verses and hadiths that stress how all issues or illness at the biopsychosocial level could be a test. For example, Allah (God) says in Qur’an (2: 155-156) SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 22 And certainly, We shall test you with something of fear, hunger, loss of wealth, lives, and fruit, but give glad tidings to the patient, who when disaster strikes them, say, “Indeed we belong to Allah, and indeed to him we will return.” In addition to many verses that indicate all kinds of issues could be a kind of a test, there are many hadiths (documented statements of Prophet Muhammad) that indicate the same message, such as; Prophet Muhammad said, No fatigue, nor disease, nor sorrow, nor sadness, nor hurt, nor distress befalls a Muslim, even if it were the prick he receives from a thorn, but that Allah expiates some of his sins for that. (University of Southern California-Muslim Student Association [USC-MSA], n.d.a, vol. 7, book 70, #545) However, it is important to keep in mind what cultural diversity, lack of education, and individual differences might bring into the room. As Kobeisy (2006) says, it is not enough to know some general information about Islam to treat Muslims (p. 59). Psychosocial elements like age, class, education, and citizenship status have a crucial role in Muslims’ experience of Islam and their understandings of mental health. It is important to know and be aware that many Muslims might see their illnesses or difficult issues as a result of lack of faith or weak faith due to not having enough knowledge about their religion due to strong cultural factors or lack of education. Thus, they could see illnesses or other difficult issues as personal faults that could bring shame to them and their families. As a result, a stigma could emerge from having difficult issues and seeking treatment from outside of their families and belief (Aloud & Rathur, 2009). Having an illness or other difficult issues might occur at the same time as a lack of faith or weak faith, but a lack of faith or SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 23 weak faith are not counted as the real reasons for having issues according to the belief. Furthermore, most of the time these illnesses or issues are a test for Muslims, as stated in the Qur’an and Sunnah, which are the primary resources of Islam. As mentioned above, the Qur’an, hadiths, lives of prophets including Prophet Muhammad, and lives of great scholars in Islam show that the prophets and scholars are the ones who have gone through the most difficult times and situations. And it is the prophets and the scholars who have the best of faith. Therefore, it is important to pay attention to whether Muslim clients and the people around them tend to have this stigma toward those who seek treatment for difficult issues. If they do, it might be helpful to clarify/challenge that with them in a therapeutic way so that they will not feel guilty or blame themselves for facing some issues and seeking counseling. Unfortunately, it is very common to see this pattern of stigma among Muslims, like “I am Muslim, praise be to Allah, and Muslims do not feel depressed and do not go to counseling.” Padela et al. (2012) explain how Muslims believe God has a direct role to heal through their worship (prayers, reciting Qur’an, invocation, etc.). It is important to know, besides daily prayers, any good deed done for the pleasure of Allah is an act of worship in Islam. In addition, the authors state that God has a role to provide healing through getting help from health care providers, imams or scholars, family, family members, and friends. The authors mention how Muslims see all illnesses as related to spiritual aspects and religious practices (prayers, rituals, etc.). Aloud and Rathur (2009) found some important key factors that keep Arab Muslims away from seeking help through formal mental health care. These factors include counselors not taking into account some critical cultural and religious concepts when they conceptualize mental health issues, as well as their lack of reaching out to this population to provide information about SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 24 counseling services. On the Arab Muslim end, some other factors include not: Being familiar with the western culture’s acceptance of seeking help, having negative attitudes and lack of confidence toward receiving help from counselors, primarily preferring other informalindigenous resources, and having some financial difficulties. Another key point is paying attention to cross-sex issues while a counselor is helping Muslim clients. In Islam, individuals of the opposite sex are not supposed to stay alone in a closed area together – unless they are married or unmarriageable (siblings, parents, grandparents, uncles, aunts...) – nor should they communicate a lot if it is not necessary. In this case, a Muslim client may want to see a same sex counselor for counseling, and if it is not possible, may talk or have some concerns about this in the sessions. Therefore, it is important to acknowledge this and validate their concerns. However, it is totally acceptable in Islam to see the opposite sex for treatment when it is not possible to have the same sex counselor to get over the issues. Cross-sex touching, including handshaking, is not permissible in Islam unless it is necessary. The recognition and incorporation of these aspects into the counseling process are crucial for the healing process. As the author mentioned earlier in this paper, the Muslim male students’ willingness to continue seeing their counselors was strongly linked to how their counselors and other health care providers treated them. Again, as the author will explain through two case studies later in this paper, Muslim clients’ esteem to seek and stay in counseling increases remarkably when they find it favorable. What to Do It can be summarized in a few sentences what counselors and other health care providers need to do in order to get over all of the factors that have been mentioned above and reach out to Muslim clients to provide counseling service to them. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 25 Counselors and other health providers need to pay attention to public stigma, stigma of illness, and stigma of seeking help, and it might be productive to work with imams or other spiritual leaders and community organizations to break down these barriers (Khan, 2006; Soheilian & Inman, 2009; Amri & Bemak, 2013). The authors also stress the importance of improving health care providers’ competence toward Muslim clients. Almost all of these studies pinpoint the necessity of tailoring the mainstream counseling approaches to incorporate the needs of Muslims. It will be a great service if it is possible to improve a culturally sensitive approach that would incorporate all or most of the major tenets/aspect of Islam. Based on what has been mentioned, the author of this paper proposes that Acceptance and Commitment Therapy (ACT) has many commonalities with the tenets of Islam and could be used effectively with Muslim clients. This could be an important point to counselors and other health providers since it is a gap in the literature and clinical work. In the next section of this paper, the author first briefly provides basic information for ACT to understand it better and then gives more detail about why and how it might be more appropriate to use while helping Muslim clients. Acceptance and Commitment Therapy (ACT) Acceptance and Commitment Therapy (ACT) was founded by Steven C. Hayes, and its roots go back to 1976 when he was studying with his first doctoral student, Zettle, about the role of language in life and especially in clinical conditions (Cullen, 2008). “ACT is always said as one word, not as individual letters” (Hayes, Wilson, & Strosahl, 2012, p. 10); their rationale behind this is that pronouncing ACT as one word creates a positive image and encouragement for engaging in life. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 26 In order to understand ACT better and especially to make it easier to understand how it might be more productive to use with Muslims, this paper will provide some more information about ACT and its place in mainstream therapeutic approaches and traditions. The founder of ACT, Hayes (2004), places ACT under the behavioral tradition among the third wave approaches like Dialectical Behavioral Therapy (DBT), Functional Analytic Psychotherapy (FAP), Integrative Behavioral Couples Therapy (IBCT), and Mindfulness-Based Cognitive Therapy (MBCBT) as one can see from the following table. Table 3 ACT’s place in behavioral tradition Firs wave Second wave Third wave Behavioral Therapy Traditional Cognitive Therapy Acceptance and Commitment Therapy (ACT) Dialectical behavioral Therapy (DBT), Functional Analytic psychotherapy (FAP), Integrative Behavioral Couples Therapy (IBCT) Mindfulness-Based Cognitive Therapy (MBCBT) In order to understand ACT in a better way, it might be helpful to explain briefly its main concepts. It has a strong and comprehensive foundation that is based on functional contextualism, relational frame theory (RFT), and psychological flexibility model (Hayes et al., 2012) as they have been shown in the following table. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 27 Table 4 Foundations of ACT Functional Contextualism Relational Frame Theory (RFT) Psychological Flexibility Model A pragmatic philosophical worldview; what is workable/useful in life Focus on the role of language and cognition to explain human success and suffering A model of psychopathology, psychological health, and psychological intervention (Hayes et al., 2012) Hayes et al. (2012) state that one has to know the psychological flexibility model to use ACT, but one does not necessarily have to know functional contextualism and relational frame theory. However, the authors stress it will be much more effective if the clinician knows more about all of them. Since focusing on the first two concepts is beyond the scope of this paper, it might be helpful to explain them briefly. Hayes et al. (2012) identify functional contextualism as the philosophy behind ACT. Functional contextualism is a philosophical worldview that focuses on what is workable/useful in life/experience. It stresses the importance of interpreting, predicting, and influencing psychological processes in the whole context. Relational frame theory (RFT) is a science that emphasizes the role of language and cognition to explain human success and suffering (Hayes et al., 2012). The authors give specific attention to RFT since they say words and language entangle humans into ineffective attempts to wage war against their own mood state. In a nutshell, words, language and cognitions could be at the heart of suffering. For example, from RFT perspective, if someone mentions any words like “water, paper, lemon, trauma, war, accident, etc.,” the mind immediately starts to focus on them SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 28 as if they are present even though they are not present/real in the moment. Similarly, a client may be affected and start to live under what language and cognition tell them. Therefore, the authors recommend the clinicians to keep this in mind. Psychological flexibility model is the third and most important component to understand to properly implement ACT. The model is based on functional contextualism and relational frame theory. Hayes et al. (2012) state that a clinician has to know the model in order to utilize ACT. They identify it as a model of psychopathology, psychological health, and psychological intervention. The psychological flexibility model consists of psychological inflexibility (as a model of psychopathology) and psychological flexibility (as a model of human functioning) (Hayes et. al., 2012). As one can see from the following hexagon-shaped figure, psychological inflexibility consists of/emerges from six core processes: inflexible attention, disruption of chosen values, inaction or impulsivity, attachment to a conceptualized self, cognitive fusion, and experiential avoidance. On the other hand, again as shown in the figure, the psychological flexibility model consists of six corresponding core processes: flexible attention to the present moment, chosen values, committed action, self-as-context, defusion, and acceptance. SPIRITUAL STRENGTH: THE USE OF ACCEPTANCE 29 Figure 4: Psychological inflexibility as a model of suffering Figure 5: Psychological Flexibility as a model of functioning Psychological Inflexibility Inflexible Attention Experiential Avoidance Cognitive Fusion Disruption of Values; Dominance of Pliant, Fused, or Avoidant “Values” Attachment to the Conceptualized Self Inaction, Impulsivity, or Avoidant Persistence Psychological Flexibility Flexible Attention to the Present Moment 
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