J Contemp Psychother (2017) 47:119–124 DOI 10.

1007/s10879-016-9354-3
ORIGINAL PAPER

Psychological Healing in Pakistan: From Sufism to Culturally

Adapted Cognitive Behaviour Therapy
Muhammad Irfan1 · Sofiya Saeed2 · Naila Riaz Awan3 · Mirrat Gul4 · Muhammad Aslam5 · Farooq Naeem6
Published online: 7 January 2017 © Springer Science+Business Media New York 2016

Abstract The current paper provides an overview of the

Background cultural and religious background of
Pakistan; the current situation of mental health in Pakistan with special empha-
Pakistan: Cultural and Religious Background sis on
cultural adaptation of cognitive behaviour therapy (CBT) in Pakistan. In the context of Sufism- Islamic Mind-
Pakistan is situated on both side of the historic Indus
fulness, it is interesting to note that it has been easy to
River, from which India gets its name, and is home
to the explain the concepts of CBT to the therapists and clients in
Indus valley civilization (Kenoyer 1991). Pakistan
has Pakistan, but the process to culturally adapt CBT in Paki-
796,095 km2 territory that include a wide variety of
land- stani culture, had to be based on patience while generating
scapes, from arid deserts to green valleys, to the
Himala- evidence for it. Our group has taken the responsibility to
yan snow-covered mountains (Naeem and Ayub
2004). To do that and so far, have been successful in the endeavours
the south is the Arabian Sea, with 1046 km of
coastline. pertaining to research and service development, described
As per the most recent estimates, Pakistan has a
population in this paper.
of nearly 180 million (Talbot 2009). The majority of the Pakistani people (95–97%) are Muslims while the remain-
Keywords Cognitive behaviour therapy (CBT) · Cultural
ing 3–5% are Christian, Hindu, or of other religious
faiths. adaptations · Sufism, mindfulness · Pakistan
Apart from the National Language, Urdu, several regional languages are also spoken by the people (Punjabi, Pashto,
Sindhi, Balochi, Kashmiri, etc.). The majority of Pakistanis live in rural areas.
Pakistan has four major ethnic groups—Punjabi, Pathan, Sindhi and Baluchi (55.6, 12.0, 18.2 and 3.6%, ✉
Muhammad Irfan
mirfan78@yahoo.com

respectively). In addition, during the last 40 years mil- lions of Afghan refugees moved to live in Pakistan due
1 Department of Mental Health, Psychiatry and Behavioral
 to the ongoing conflicts in Afghanistan (Craig 2014). Sciences,
Peshawar Medical College, Peshawar-Riphah

The geographical situation of Pakistan both historically

International University, Islamabad, Pakistan
and currently creates threats and opportunities. The Khy- 2
Fatima Institute of Research and Mental Health Sciences,

ber Pass, in the North of Pakistan has been the gateway

Karachi, Pakistan
to India for thousands of years for both foreign traders 3
Clinical Psychologist, Lady Reading Hospital Peshawar,

and invaders. This also meant mixes of the cultures and

Peshawar, Pakistan
traditions. Persians, Greeks, Romans, Turks, Arabs,
Cen- 4 Clinical Psychologist, Sir Ganga Ram Hospital, Lahore,
tral Asians, British and Russians (in that order), have
Pakistan
all moved through and lived there (Bearden 2001). The 5
Clinical Psychologist, Fountain House, Lahore, Pakistan

famous Silk Route also passes through Pakistan. The

6 Department of Psychiatry, Queens University Canada,

northern areas of Pakistan (Khyber Pakhtunkhwa, and

the Kingston, Canada
Federally Administered Tribal Areas) are acknowledged
1 Vol.:(0123456789) 3
120 J Contemp Psychother (2017) 47:119–124

by many to be the origin of Hinduism and cradle of Bud- dhism (Rahman 1993).
Pakistan has a long history of adversity. Independ- ence from India in 1947 in itself was a bloody and trau- matic
event, causing a vast number of deaths (approxi- mately 200,000–500,000), and destruction on both sides of the
border (Brass 2011). Pakistan has also experienced some of the worst floods and earthquakes in the region and has
faced several problems due to its involvement in the Soviet-Afghan War (Johnson and Mason 2008). A recent
complication is the rise of extremist elements who believe in a ‘purist’ form of the religion that can be in conflict
with Sufism (an orientation or denomination of Islam that focuses on mysticism and spiritualism).
Current Status of Mental Health in Pakistan
Traditional Healing Practices in Pakistan
Pakistan’s varied history of migrations is reflected in the healing traditions that are followed there today. For exam-
ple, Pakistani physical health healers can be observed using old Greek, Arabic, Indian and Chinese methods of
healing. Additionally, faith and religious healers use magic, palmistry, numbers, cards and Sufism to help peo- ple
for sexual, psychological, and relationship problems (Farooqi 2006). The main reasons for consulting these healers
are proximity, affordability, availability, family pressure, and the strong beliefs and opinions of the com- munity
(Shaikh and Hatcher 2005a).
Faith healers and traditional medicines are often used for therapeutic purposes in Pakistan. Researchers
(Mubashar and Saeed 2000) reported that about 40% of total attendees of a faith healer qualified for a psychiatric
diagnosis, the most common ones being depressive ill- ness, psychosis, and epilepsy, with depressive illness and
dissociative disorders being more common in women and psychosis among men. A similar study found that more
male patients sought multiple traditional healing methods for their various psychiatric disorders, including schizo-
phrenia, affective, anxiety, somatoform and personality/ conduct disorders (Farooqi 2006). It has been suggested that
without them, it is not possible to cope up with the situation by the limited number of mental health profes- sionals
(Naeem 2005). In another study, for people with mental health problems in Pakistan, Faith healers have been
reported to be the major source of care, particularly women with little education (Farooqi 2006). India and
Bangladesh, in the neighbourhood, share the same find- ings (Chadda 2001; Roy 1997).

13
Psychology in Pakistan
Most universities in Pakistan have a psychology depart- ment. For example, in Lahore, the capital of Punjab prov-
ince, there are more than 12 psychology departments attached with universities. The programmes offered by these
departments include both bachelor and master level programmes. However, to practise as a psychologist in
government sector, it is now becoming necessary to do a university based post graduate diploma. The training pro-
vided in these diplomas and otherwise, uses an eclectic approach. Some of the departments have their own coun-
seling centers (mainly attended by the students), in addi- tion to having access to local hospital patients. There is no
national institute for accreditation or registration. Most psychologists, after postgraduate qualifications, join Non
Government Organisations; while a few join the psychiatry departments of public hospitals where they work as
generic mental health workers, involved with history taking and assessments in the outpatient clinics (These clinics
are like drop in centres where anyone can self refer themselves, for assessment). Psychologists mainly gather under
two pro- fessional bodies in Pakistan, The Pakistan Psychological Society and Pakistan Association Of Clinical
Psychologists (Naeem et al. 2010).
Psychiatry in Pakistan
In Pakistan, 10–16% population suffers from mild to mod- erate psychiatric illnesses, 1% suffers from severe mental
illnesses and 1.6% children between the age of 3–9 years, suffer from severe mental retardation (Gadit and Khalid
2002). The prevalence of epilepsy was found to be 9–16 per 1000. For neuropsychiatric conditions or for other
psychi- atric conditions, there is no reliable data available (Karim et al. 2014). The last 10 years have witnessed
opening of numerous medical colleges in Pakistan. Almost every medical college has a psychiatry department with
varied level of the quality of service, they offer. Apart from these departments, every distrcit hospital has an attached
men- tal health unit (some, unfortunately, do not have properly trained mental health professionals available).
However, the basic health units responsible for providing primary care to rural populations, do not have mental
health professionals attached to them.
It has been estimated that there are nearly 1.5 inpatient beds per 100,000 population in Pakistan. The number of
psychiatrists for the same population is 0.3. The main resi- dency programme is run by College of Physicians and
Sur- geons Pakistan which offers Membership (MCPS, 2 years) and Fellowship (FCPS, 4 years) trainings and
exams. By 2015, 231 MCPS and 235 FCPS have qualified the respective exams. There have been Diploma in
Psychiatric
121 J Contemp Psychother (2017) 47:119–124

Medicine and MD Psychiatry offered by a very few Uni- versities but the exact figures of qualified psychiatrists who
have obtained these diplomas are not available. Majority of the qualified psychiatrists are based in major urban
centres in Pakistan (Gadit and Khalid 2002). Most departments of psychiatry have limited facilities for further
education and even rarer job opportunities for psychologists and nurses and there were only 52 trained psychiatric
nurses in 2001. There is no programme for mental health social workers (Naeem 2005).
Sufism‐Islamic Mindfulness
Mindfulness-based techniques have been, applied for thou- sands of years in human endeavours, found to be of great
value by Hindus, Buddhists, Christians and Muslims (Knight 2007). Similar to Christianity and Judaism, mind-
fulness tradition was developed in Islam well after its foun- dation and the mystical tradition of “tasawwuf” (Sufism)
was developed in ninth century AD (Armstrong 2002). Sufism is a large family of tariqat (teaching lineages),
employing a vast variety of techniques (Knight 2007). The heart of Sufism is a search for a direct confrontation with
the Divine, often visualized as Love or as an all consuming fire (Fadiman 1997).
Sufis used poetry and spoke in stories and used symbols. Probably the most renowned Sufi in the Western world
is Rumi. One popular means of communication of Sufi ideas is qawwali, particularly in South East Asia. Sufi
philoso- phy has influenced many areas of thinking both within and outside of Islam. Sufis described Lataif-e-Sitta
(“the six subtleties or faculties”); “Nafs, Qalb, Sirr, Ruh, Khafi, and Akhfa” designating different “organs” of the
body or facul- ties of sensory and supra-sensory perception.
The development of Nafs has been described to pass through the following stages; Nafs-e-Ammara or The Com-
manding Self, Nafs-e-Lawwama or The Regretful Self and the Nafs-e-Mulhama or The Inspired Self. Sufies describe
Nafs-e-Ammara to have seven parts, which must be defeated to reach the highest form of the Nafs, and include;
False Pride (Takabbur), Greed (Hirs), Envy (Hasad), Lust (Shahwah), Back Biting (Gheebah), Stinginess (Bokhl)
and Malice (Keena). Once a person overcomes these problems, the stage of awakening is achieved. On this level, the
con- science is awakened and the self accuses one for listening to one’s ego. At this stage, the person asks for
forgiveness. A good deed must be done immediately and there should be no laziness. It is also advised that the
person must look at his good acts with contempt, otherwise there is a risk of becoming self-righteous. It is also
expected that the per- son on Sufi’s path keeps his good acts secret, so that oth- ers don’t praise him. Eventually,
when a person reaches the stage of Nafs-e-Mutma’inna (The Contented Self), the
1 3 person is pleased with whatever comes from Allah and doesn’t
live in the past or future, but in the moment.
These teachings are direct interpretations of verses from the Quran, which also refers to “Nafs at peace” (Qur’an
89:27). This is the ideal stage of ego for Sufis. On this level, one is firm in one’s faith and leaves bad habits behind.
The soul is at peace and the person has relieved himself of all materialism and worldly problems and is satisfied with
the will of God.
The Sufis practice a variety of devotional practices. These practices focus on helping a person achieve mastery of
his Nafs. Sufis agree that a person cannot walk on the path of Sufism alone and needs a master who can diagnose the
ailments of his heart and suggest an appropriate treat- ment. Commonly used practices by the Sufis include dikar
(remembrance of God), muraqba (meditation), breathing and exercises of focusing and pilgrimage (visiting tombs of
saints, great scholars, and righteous people).
The four popular Sufi orders in South Asia are the Chishti, the Qadiriyyah, the Naqshbandiyya, and the Suhra-
wardiyya Order. Of them, the Chishti order is the most fol- lowed. This order was introduced by Khwaja Moinuddin
Chishti who came to India from Afghanistan in 1192 AD and lived in Ajmer.
Interestingly, mental health professionals in our initial studies were a bit reluctant to accept the place of Sufism in
their clinical work.
Cognitive Behaviour Therapy in Pakistan
Cultural Adaptation of CBT in Pakistan
Our group has culturally adapted CBT in Pakistan. Cog- nitive behaviour therapy (CBT) was selected for multiple
reasons: (1) it is short-term, focused, cost effective and is evidence based, (2) there was at least some literature
describing its use with patients from collectivistic back- grounds, and (3) for practical reasons—most of our team
members were trained in CBT. However, the existing evi- dence from the literature also points out that CBT might
need adapting for it to be effective with people from tra- ditional cultures (Hays and Iwamasa 2006; Scorzelli and
Scorzelli 1994).
A series of qualitative studies were conducted, which were underpinned by an ethnographic approach (Naeem et
al. 2014). Culturally sensitive CBT thus developed was tested in small feasibility studies and was found to be effec-
tive. These studies involved practicing clinical psycholo- gists (n = 5) who were interviewed about their experiences
of providing therapy to depressed patients (Naeem et al. 2010); depressed patients (n = 9) that were asked about
presenting symptoms, referral behaviour, attribution styles,
122 J Contemp Psychother (2017) 47:119–124

acceptability of talking therapies, and obstacles in its deliv- ery (Naeem et al. 2012); and university students (n = 34)
where the aim was to find out the extent to which CBT was consistent with their personal, religious, family, social
and cultural values, and come up with culturally equivalent terminology that can be used in CBT (Naeem et al.
2009). As a result of these studies, an adaptation framework was developed that guided the CBT adaptation process
(Naeem et al. 2009). Preliminary evaluation of adapted CBT found it to be effective in primary care settings (Naeem
et al. 2011). Alarger randomized controlled trial (RCT) was then conducted that demonstrated that a brief version of
this culturally adapted CBT was more effective than ‘treatment as usual’ (Naeem et al. 2015). Amulti-centre
randomised controlled trial also found a culturally adapted, CBT-based (CaCBT) self-help intervention to be
effective (Naeem et al. 2014). The self-help manual is available for use (Naeem et al. 2013), and semi-structured
interviews can be obtained from our group on request.
Further studies, using the methodology that has already been developed by our group, aimed to culturally adapt
CBT for psychosis (Naeem et al. 2014). A total of 92 inter- views with mental health professionals, patients and
their carers (n = 29, 33 and 30, respectively) were conducted by psychologists. CaCBT for psychosis has also been
tested in Pakistan in inpatient settings (Habib et al. 2014). Abrief version of CaCBT for patients with psychosis was
tested in a RCT, and was found to be significantly more effective (Naeem et al. 2015).
The guidelines developed from the above mentioned work were also used to deliver and test a brief psychologi-
cal intervention for self-harm (Husain et al. 2014) and a group psychosocial intervention for depression (Husain et
al. 2013) in Pakistan.
All of the studies mentioned above provide the informa- tion for and context in which the issues of cultural
adapta- tion are discussed below.
In our previous work in Pakistan and the United King- dom, to culturally adapt CBT for psychosis, open ended
interviews were conducted by a psychiatrist trained in CBT and qualitative methods. We therefore wanted to develop
semi structured questionnaire which could be used by untrained interviewers, under supervision, thus reducing the
cost and further standardizing the process of inter- views (Farooq et al. 2009, 2010, 2014). In order to do this,
members of our team, who had worked together on previ- ous project read and re-read the interview transcripts from
previous studies and their results. This exercise focused on both the topics and the questions used in our past work
and formed the basis of semi structured interview guide. These semi structured interviews consisted of open ended
questions, with prompts and guidance on exploratory ques- tions. Once the initial list of questions had been
developed,

13
these questions were reviewed for both content and format, separately. We wanted to explore pre-determined themes,
but were also responsive to issues that were raised in dis- cussion, to enable us to explore the difficult or contentious
issues. Minor adjustment in the wording of the questions were made to further refine the interview questions con-
tinued throughout the study, based on feedback from inter- viewers and research team.
Process of Adaptation of CBT
The process of adaptation of CBT starts with gathering information from the different stake holders using a quali-
tative methodology. This information is then analysed to develop guidance that can be used to deliver culturally
adapted CBT. The therapy material or manual is then trans- lated, and culturally adapted in the light of guidance
devel- oped from the qualitative analyses. The adapted therapy is field tested in the last step, and adjustments are
made to further refine the adaptation.
The core of interviews and focus groups is (1) to explore the beliefs of the patients with a given illness, its causes
and the treatment, especially non-medical treatments, and patient’s experience of any non-pharmacological help they
had received, (2) to gain an understanding of carers’ views about the problem, its causes and treatment, and their
beliefs about help seeking and any non-pharmacological treatment, and (3) to explore the experience of health pro-
fessionals, including therapists, who help patients with the given problem and what barriers they have to overcome
in helping these patients. Questions were asked to further identify techniques the helpers believed needed modifying,
and those which they found useful. These semi-structured interviews can be obtained from the first author on
request.
Finding From the Studies
Cultural adaptation of therapy goes beyond translation of a therapy manual. It involves multiple aspects of therapy.
Following areas that need attention during the adaptation, which are referred to as the ‘Triple-A’ principle:
I. Awareness of relevant cultural issues and preparation
for therapy II. Assessment and engagement III. Adjustments in therapy techniques (technical adjust-
ments)
There are in turn three subareas, under the heading awareness and preparation that deserves to be mentioned here;
123 J Contemp Psychother (2017) 47:119–124

1. Culture and related issues (culture, religion and spir- ituality; language and communication; family-related
issues), 2. Capacity and circumstances, and 3. Cognitions and beliefs.
Beliefs about the causes of mental illness can influence decisions about choice of treatment and help-seeking
path- ways (Lloyd et al. 1998). Exploring a patient’s beliefs about illness and its causes and most importantly their
expecta- tions from the health system is important (Magiorkinis et al. 2013; Nestler et al. 2002). Language and
communica- tion play a vital role in helping both clients and therapists understand each other and in delivery of
effective therapy. Pakistani patients often live within an extended or joint family. Involving family can improve
engagement with therapy, ensure the completion of home-work assignments, and can even improve follow up.
An understanding of the health care pathways is essen- tial in adapting therapy. The pathways to care and help-
seeking behaviours are related to social systems, cultural and religious beliefs, and health systems (Shaikh and
Hatcher 2005b). Patients with psychosis are more likely to seek help from faith or spiritual healers (for example, the
imam, a person who performs religious duties in a mosque, or pirs, practitioners of Sufism), while those with depres-
sion and anxiety often present with somatic complaints to traditional or non-traditional healing systems (for
example, to hakims, practitioners of old Greek or Chinese medicine; or homeopaths) (Naeem et al. 2012). Similar
pathways have been reported for patients in India and Africa (Saravanan et al. 2007; Sorsdahl et al. 2010).
Dysfunctional beliefs and cognitive errors may vary from culture to culture (Padesky and Greenberger 1995).
Research on people from Turkey provides evidence of such variations (Sahin and Sahin 1992). Beliefs related to
dependence on others, the need to please people close to you, the need to submit to the demands of loved ones, and
sacrificing one’s needs for the sake of family are common among Pakistanis. It is worth exploring family and other
community members’ beliefs to assess whether these are acceptable or whether these are dysfunctional beliefs.
Assessing beliefs about treatment and treatment provid- ers can be very useful. Exploring a patient’s beliefs about
the best treatment and the healer can give an idea of the patient’s expectations. This will also give the therapist some
idea of how realistic the expectations are. For example, questions about who the patients believe can treat their ill-
ness, what the ideal treatment for their illness is, what they know about CBT, what they expect from CBT, and
whether they have received any psychotherapy/CBT in the past, can provide important information and possible
pathways for adapting CBT to best fit the patient. Assessing somatic
1 3 concerns is also important. Many patients with anxiety or
depressive illness present with physical complaints (Naeem et al. 2014; Patel et al. 1998). Exploring patients’
concerns about these symptoms helps with engagement. Exploration of stigma is an important part of the
assessment, as it might be preventing patients or their family from seeking help.
Once therapy begins, adjustments can be made along the way. Experienced healers from this cultural background
use stories and images to convey their messages. Stories can be highly successful in activating change (Naeem et al.
2015). Stories are especially useful when used along with the images provided in the self-help reading materials
(Naeem et al. 2013). A more directive counselling style might be preferable to a collaborative approach. The Asian
model of spiritual healing is a saint or a guru who gives sermons, as opposed to teaching through a ‘Socratic
dialogue’ that is preferred in individualistic cultures. Socratic dialogue and ‘downward arrow’ techniques are
particularly difficult to use with this group. Patients feel uncomfortable if Socratic dialogue is used without sufficient
preparation. It is impor- tant to addresses patients’ presenting concerns—for exam- ple, their physical
symptoms—instead of conducting ther- apy in a mechanical manner.
It can be readily seen that this adapted CBT had numer- ous differences from the standard CBT, especially in
terms of assessment and engagement, in areas of awareness and suggested minor adjustments in therapy in its form
as well as its delivery.
Way Forward
Healing systems in Pakistan are based in a rich variety of healing systems, which are underpinned in biological, psy-
cho-social and spiritual traditions. These include, Greek, Chinese, Budhism, Indian and Muslim healing practices.
Although, CBT has been culturally adapted in Pakistan and has been found to be acceptable, feasible and effec- tive,
psychologists and psychiatrists heavily use examples from religious and spiritual practices, in particular Sufism. It
therefore seems only natural that CBT and other western approaches to psycho-social interventions should explore
combining their use with Sufism or even Mindfulness approaches. This will not only make the western therapies
more acceptable, but will also help clients achieve their spiritual needs.
Compliance with Ethical Standards
Conflicts of interest There are no potential conflicts of interest.
Research involving human and animal rights The paper does not involve a research on human participants and/or animals. The
studies mentioned have been discussed as part of the review of literature.
124 J Contemp Psychother (2017) 47:119–124

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