Spirituality as a concept and a practice has been a part of societies throughout history. Almost 90% of the world’s population is involved in some sort of spiritual practice making it a prominent aspect in an increasingly globalised world 1. Although Global Health is inherently an interdisciplinary field, the relevance spirituality has is currently greatly underestimated, particularly with regards to mental healthcare provision. This is particularly discouraging from a Muslim perspective given its importance within Islam. Despite this, many Muslim nations have chronically underfunded mental health services and also overlooked the value of integrating spirituality within healthcare provision, something which arguably contradicts the Islamic tradition. Instead, in Islamic terms a great importance is placed on not only health itself, but also both spirituality and its links to mental well-being. I will begin by considering how spirituality can be viewed and employed as a coping mechanism for some people. This will demonstrate its use in psychiatric assessment and intervention, whilst perhaps also being utilised through social support networks and community healthcare delivery.
Spirituality is concerned with the human spirit or soul and one’s transcendent connection to a divine being 2,3. Although traditionally this is associated with religion, the Bradford Care Trust suggest that spirituality can refer to “the essence of human beings as unique individuals” which has given scope to non-religious people practicing spirituality 4,5. Moreover, it is used as a coping mechanism across different cultures, for example, an American study of 330 hospitalised patients found that 90 percent reported they used spiritual beliefs and practices to cope at least a moderate extent 6. Similarly, amongst Muslim communities practicing forms of spirituality is encouraged as a method to improve coping and provide greater meaning to life 7. Spirituality has also been shown to have positive outcomes for depressed women with HIV in terms of both the quality of life and immunological function improvements 8. Thus, the increasingly wide spectrum of people engaging in spirituality, even using it as a coping mechanism, warrants greater attention for what it means to people and their health.
From an Islamic lens, health is considered a virtue as humans are said to be “honoured” by Allah as well as having the right to live 9. In many ways, spiritual health is integral to this overall health and well-being. Indeed, many within the Islamic tradition would argue a strong association between the outward psychological issues people face and the diseases of the spiritual heart. This spiritual heart can be seen as the essence of man and some would even consider its diseases to manifest as mental health related issues 10. Regardless, there has traditionally been a definite link between spirituality and healthcare provision which is more practically seen through the bimaristans of the so called ‘Islamic Golden Age’ from the eighth century to beginning of the modern era.
The Persian word, bimaristan, means a place of disease and traditionally they performed the role of hospitals in the Islamic world in pre-modern times. Moreover, the concept of bimaristans in Islamic history can be traced as far back as the time of the Prophet Muhammad ﷺ when a mobile military tent was set up during battle 11,12. Indeed it is within the Prophet Muhammad’s ﷺ teachings for Muslims to actively seek medical attention, and in one saying he said “[y]es, 0 you servants of Allah take medicine as Allah has not created a disease without creating a cure except for one. They asked which one, he replied old age” 13. In consequence, not only did bimaristans hold an important role within Islamic society to provide healthcare, but they also incorporated mental health services. For example, one of the early bimaristans with a specialised section for the mentally unwell patients was built in 872 AD in Cairo 14. Within this, disease severity was categorised and patients were separated accordingly. This pattern was repeated frequently in bimaristans and some buildings used iron bars to isolate aggressive patients and prevent harm to others 11. Evidently, within Islam spirituality and mental well-being can be viewed as integral to the virtue of health.
Whilst I have discussed the values of spirituality, it is also pertinent to assess its potential within psychiatric assessments and management. Psychiatry has previously distanced itself from religion and spirituality including Freud even linking religion with neurosis 15. This has steadily been changing as the Royal College of Psychiatrists has a specific group on Psychiatry and Spirituality, as well as the World Psychiatric Association establishing a section on Psychiatry and Religion. Despite this, more action is needed in the clinical setting such as including greater consideration of patients’ spiritual needs during an assessment. For instance, going beyond simply knowing the denomination a patient belongs to and enquiring further into their spiritual beliefs can better assist healthcare providers in utilising the coping mechanism ideas suggested above. Likewise, understanding the patients’ beliefs could in turn be helpful is understanding their mental health status and other health attitudes 16. Moreover, the role of spirituality in health attitudes and beliefs is very important in some cultures. This is illustrated by certain South Asian migrants within the western world who prefer traditional spiritual healing practices over western mental health care options 17. Hence, it is essential the psychiatric assessment and management of patients should better incorporate how important spirituality is to a patient to effectively address their needs.
In this regard, the structure of bimaristans during the Islamic Golden Age becomes salient as they sought to integrate mental health provision with an Islamic basis. Whilst most of European medicine saw the mind and body as separate entities, Muslim physicians in the Islamic regions did not see this division allowing for greater exploration of the human mind 18. For instance, physicians such as Ibn Sina understood “physiological psychology” in treating diseases which had a mental aspect to them, including using the pulse rate as means to measure stress response 19. Likewise Al Razi brought forward innovate discoveries and definitions of mental health symptoms as he looked to integrate psychotherapy within healthcare through his book titled ‘El Mansuri’ dan ‘Al Tibb al-Ruhani’ 20. In addition, the works of the Muslim scholar Al-Ghazali extend this idea as he argued that mental health itself can be somewhat encapsulated within spiritual health. For example, he viewed anxiety as a mental disease established within the spiritual heart, which itself mirrors the state of the soul with regards to its purity 21,22. Hence, in this regard, anxiety was viewed as a disease of the heart requiring purification through spiritual acts in the same way as other spiritual diseases such as anger, hatred, envy, sadness, pride and others. Thus, in Islamic terms both spiritual and mental health play key roles within the overall health and well-being of an individual. As a result, traditional medical practice in Islamic tradition allowed the physician to go beyond the physical realm and to evaluate the patient holistically with a multi-faceted approach.
Another key reason spiritual health warrants greater attention within Global Health is due to the social networks it exists within. One component of this is the mental and social well-being benefit patients can obtain by being a part of a community or spiritual group 2. In addition, faith groups or leaders could play a greater involvement in the mental healthcare patients receive. In relation to this, the Lancet called for development of human resources for mental health including diversifying and expanding the current workforce 23. Accordingly, this should include forming partnerships between mental healthcare teams and faith groups. To support this, there is evidence to suggest certain groups prefer to contact their clergy or faith group regarding mental health problems in comparison to psychiatric professionals 24. Hence, creating working partnerships would then better allow for patients to access healthcare professionals through their clergy and even have a more holistic management approach if they wish. Ultimately, the spiritual social networks already exist. Therefore, improving the community-based medicine strategies as suggested above will surely improve patient healthcare access and management plans.
Without doubt a key barrier to improving the inclusion of spirituality in Global Health is the underestimation of global mental health impact in general. There has been a growing understanding that mental health problems could be improved even in low-resource settings and more importance has been placed on mental health in the global discourse on development 25. However, this has not solved the issue as most low-income countries invest less than 1% of their health budgets in mental health services and fall below acceptable standards of provision 26. Implementation of spirituality can only take place alongside whole global mental health improvement.
In conclusion, I have discussed the overlooked yet key role spirituality has as a discipline within Global Health. As an interdisciplinary field, Global Health is neglecting spirituality, the importance it has in many patients’ health beliefs and the potential benefits it has for these patients. The diverse engagement of spirituality across the world, particularly as a coping mechanism, should be given greater attention. Health care providers can only appreciate the importance some patients may place on their spiritual health if it is better implemented within their assessments. This will assist management options and could include integration of a community-based medicine approach with local spiritual leaders and networks. Likewise, including spiritual networks within the Global Health disciplines will improve access to healthcare and provide a more holistic management plan to those patients who require it. However, enhancing the role of spirituality in Global Health will take time and this is made more difficult due to the wider problem of mental health underfunding. The Global Health agenda must embrace these disciplines to be truly interdisciplinary and meet the needs of a vast number of people. This is especially pertinent for Muslim healthcare providers with an interest in mental health services or Global Health fields. Evidently, the Islamic tradition promotes health and values spiritual and mental well-being. However, the extent to which this is integrated into healthcare provision is certainly below ideal standards. In this sense, great inspiration can be taken from the bimaristans and scholars of previous eras.
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