Spiritual and religious Islamic perspectives of healing of posttraumatic stress disorder

It is known today that psycho-trauma and PTSD cause different levels of mental and social dysfunction. Human spirituality and capacity to meet further life diffi culties become severely damaged. There is wide accepted attitude today that in holistic approach in process of healing PTSD and psycho-trauma is necessary to include other professionals from community resource regarding needs of trauma victims. In Bosnia and Herzegovina after very severe war (1992-1995) as mental health professionals, we are faced with increasing number of different mental health disorders as result of severe trauma experiences. Regarding community based care orientation it is necessary to include and religion professionals. According national and religious background of majority of our population in Tuzla Canton that is Muslim, we meet spiritual needs of our clients as needs for Islamic explanation of life and death meaning. Our clients need to talk about spiritual issues in daily therapy and to practice daily religious rituals. Regarding that in this paper we tried to interface Islamic principles and it’s benefi cial toward psycho-trauma and PTSD, as well as Muslim perspectives in attempt to apply spiritual practice in therapeutic tools for better effi cacy in spiritual healing of mental dysfunction’s of believers who survived severe trauma, especially war trauma. Review Article Spiritual and religious Islamic perspectives of healing of posttraumatic stress disorder Mevludin Hasanović*, Izet Pajević and Osman Sinanović Department of Psychiatry, University Clinical Center Tuzla, School of Medicine, University Tuzla, 75 000 Tuzla, Bosnia and Herzegovina, Tuzla, Bosnia *Address for Correspondence: Mevludin Hasanović, Department of Psychiatry, University Clinical Center Tuzla, School of Medicine, University Tuzla, 75 000 Tuzla, Bosnia and Herzegovina, Tuzla, Email: hameaz@bih.net.ba Submitted: 12 September 2017 Approved: 22 September 2017 Published: 25 September 2017 Copyright: 2017 Hasanović M, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Introduction
Intensive physical or psychical traumas can devastate human psyche and leave personality of traumatized in ruin. There are strong evidences about that provided from psychiatrists and psychologists in existing scienti ic and professional literature [1]. Events that are integral part of wars, natural catastrophes and similar situations brings to survivors plenty of pain and sufferings which overwhelmed their psychophysical capacities, so it can lead to collapse of internal defense mechanisms and appearance of psychical complains that put normal life in disorder [2][3][4][5].
As Wilson and Moran [1], emphasised, extreme trauma after devastating of human psyche and leaving human personality in ruins it can completely put in disorder religious believing and spirituality which are integral parts of human existence. Therefore, today faced with reality of entire tragedy and insecurity of human existence onto Earth, all mental health professionals and people from religious profession have to understand the in luence of psycho-trauma and PTSD on human spirituality and personality [6,7].

Infl uence of psycho-trauma and PTSD onto human spirituality
Clinical studies maintain statement emphasized in DSM III and in the last edition of DSM IV, that extreme trauma in luence onto "important ields of functioning" of many survivors. Psychological trauma and PTSD can have severe negative impact on spiritual faith or faith in God, so it can decrease social and professional skills.
In our clinical work with survivors of early childhood trauma or different traumas in adult period we are very often faced with males and females that suspect regarding belief in God. They think loudly, asking themselves for guilt, why they are "punished so cruel". Mainly they regard that they are innocent and there is "God's injustice" executed over them, and they are not ready to accept it.
In souls of traumatized, feeling of throwing off from human and God's care and protection systems which supporting lives appear. Therefore they stay completely spiritually abandoned, completely alone. In that way all relationships either the most intimate family bonds or the most abstract associating in community and religion become pervaded with feeling of alienation and disconnection [1,8].

Bosnia and after war conditions
War affects both the soldiers ighting on the ground and the civilian population amongst whom they ight. Recent con licts, including those in the Balkans, Libya and Syria, have involved much ighting within highly populated urban areas. In the large civilian populations caught up in these con licts, children are vulnerable [9]. After inishing war in [10], with so many cases of trauma, stress and sufferings of whole population [11,12], people and professionals met lot of needs for improvement of understanding what is going on with public mental health side by side with reform and development of mental health care. Mental health in the life of Bosnia and Herzegovina citizens' regardless age, gender, nationality or profession is seriously damaged. In this context, we found in our study [10] about the epidemiology of Post Traumatic Stress Disorder among children who were displaced by the war in Bosnia that the severity level of the PTSD symptoms and social dysfunction was most severe in the Srebrenica group of children, then in the Zvornik children and inally in the Bijeljina group. The prevalence of PTSD differed in a statistically signi icant way between the Srebrenica group (73.9%), the Zvornik group (60.8%) and the Bijeljina group of children (47.6%) (χ²=9.854, df=2, p=0.007). Thus, not surprisingly, there is a strong correlation between the incidence and severity of PTSD and the severity of con lict which the children were exposed to. Srebrenica, which witnessed the massacre of its male population, demonstrated the highest incidence of PTSD among children and areas where there was less ighting have lower incidences of PTSD in children [10]. It is important that both military and political decision makers should bear in mind the potential mental health consequences of war, especially in urban areas. It is the responsibility of the medical profession to educate decision makers to consider the consequences of exposure of children to war trauma [9].
Our clinical experiences identi ied stress as a major issue, because the number of PTSD and trauma related clinical issues increased seriously. Mental health professionals and people in needs together with their family members are concerned with this, so they showed needs for mental health community based care. Hasanović et al., Majority of our clients that we treated in the war and postwar period are soldiers of BH Army, their family members, civilian victims of war among them refugees, widows, adolescents and children who belong to Muslim cultural circle. They belong to Islamic spiritual background regardless their active or passive participation in daily religious rituals.
Psychological trauma and post-traumatic stress disorder (PTSD) may have an intensive negative impact on a patient's spiritual beliefs or his/her belief in God; this effect may diminish the social and professional skills of many survivors. In the same time researches showed that religion plays a coping role among patients with medical and mental health illnesses. During the war in Bosnia-Herzegovina (1992-1995) the whole population, regardless of age, gender, nationality or profession, suffered severely. During the pre-war period in communistic Yugoslavia religious believes altered with atheistic public life styles. Additionally, war traumatization had a negative impact on spirituality and religious beliefs. In the series of case reports we intended to describe and assess the impact of a session of group psychotherapy, with spiritual topics and content, which was offered to patients who needed to reestablish religious beliefs. The patients who come to the Psychiatry Clinic because of trauma-induced mental health problems and who we are interested in strengthening their spirituality met each other in the group regardless of their religious or spiritual conviction. During different clinical treatments most of them show needs to talk about spiritual perspectives of meaning of life; death and signi icance of martyrdom sacri icing of killed close relatives. During individual and group therapies very often need for the Islamic explanation of life in this world and hereafter appeared. Our clients express whishes to have daily rhythm of prayers during staying in clinic. So we provided two rooms, one for Muslims (masjid) and another for non-Muslims, mainly Christians, as Prayer rooms. Patients found it very suf icient and helping for their conditions of mental dysfunction. They feel more privacy similar at home. The supportive and empathetic presence of such group in the community helps to prevent withdrawal and isolation, alienation and deviation of traumatized persons. The presence of such group facilitates the rehabilitation process of the victims, allowing them to understand that people are available to them in certain critical moments, to help, to offer protection or to console. Groups like this one, offer long term social and spiritual support to extremely severely traumatized victims [3].
Regarding actual problems which we are as mental health professionals faced in postwar BH and historic roots of mental health care, which in our social reality absorb spiritual forces from Islamic background [13], this paper has aim to interface arguments between human spirituality in Muslim perspectives on one side and psycho-trauma with PTSD and efforts for its healing using Islamic principles from another side. About dynamic effects on prayers/related religious behaviors on symptoms of PTSD we need additional researches amongst BH war veterans and members of their families.

Muslim concept of mental wellness and illness
Islam isn't religion only, but holistic life system of rules for individual as well as for human community, which completely initiate onto all aspects of healthy somatic and mental life. Islamic belief and it's practicing ills up Muslims with security and peace as well as with optimistic regard onto life with looking into full human reality [14][15][16][17][18]. During the last few decades, a signi icant amount of attention has been given to the role of religion and spirituality in clinical practice. Professionals, researchers, and academicians have contributed to the literature indicating further progress [19].

The role of daily prayers in achieving and keeping mental stability
Al-salah, Islamic prayer, is strict religious obligation of matured, aware and mentally normal Muslim, ive times per day, from early youth to the end of one's life. It's realising engages somatic, soul and spiritual personal potentials on individual as well as on social plan [20,18].
Regularly practicing of Al-salah makes will stronger and ability of self-control, it induces tendency for self-perfecting and for modeling of one's own personality, for gaining of new knowledge and practical applying of it. Individuals who regularly practice Al-salah distinguish themselves with more correct and more explicit life orientation, with beter and stronger character, with more constructed identity, stability and pragmatism. Islamic life style has positive in luence on the mental health and human individual stability, so it represents one very ef icacy way of achieving higher resistance toward different stressful factors in everyday life and particularly in extraordinary, catastrophes situations like war is. In concordance with that it increases ighting readiness of soldiers onto higher level and make them more competent to be faced with any dif iculties that appearing with war happenings and devastation.
In our research (2017) we compared the outcomes among a hundred healthy Bosnian war veterans who pray (n=50) and who do not pray (n=50), who were not suffering mental disorders after the Bosnia-Herzegovina war (1992-95). The highly religious group consists from individuals who perform ive obligatory prayers every day, and another group of individuals who do not practice any daily prayer. War veterans who prayed had signi icantly higher levels for: incorporation, self-protection, and for reactive formation; but signi icantly lower levels for regression, compensation, transfer, no-controlling, oppositional and aggressiveness than their peers who did not pray. Though, practicing religion (regular performing daily prayers) is associated with reduction of tendencies towards the tendency for risk, impulsiveness, and aggression. It is also associated with successful overcoming of emotional con licts in war veterans who practiced religion than their peers who did not practice religion [18].

Prayers (Al-salah) as therapeutic tools
Review of the available professional and scienti ic literature reveals a dearth of examination of religious involvement, praying the ive daily prayers every day from a psychological lens. The relationship between religious involvement and mental stability of war veterans has remained outside the main interest of scientists who are engaged in studying trauma and posttraumatic consequences from others angles [18]. There were only few research studies on Muslim-based religious practices and their stress reduction and life-enhancing qualities [20]. Amongst that, one of the irst, done by Chishti [21], has been focused on Su i practices and their therapeutic ef icacy. He discussed in his study both the spiritual and physical enhancing aspects of Muslim ritual prayer (Salah) and meditation (dhikr). Islamic Su ism, in common with other traditional religions, has long been known to have a psychotherapeutic perspective and has been used over time to help people to overcome trauma and stress. The ritual movements associated with the Su i Dhikr may involve a form of bilateral stimulations (BLS) like in Eye Movement Desensitization and Reprocessing (EMDR) therapy, and that this might underline some of the therapeutic effectiveness of Dhikr and Su ism [22]. The psychotherapeutic contributions of Medieval Muslims have previously been classi ied into two major themes. One of these is medical psychotherapy, which was practiced by physicians to help patients with psychological and psychiatric problems [23]. The other type of psychotherapeutic contribution is that within certain religious practices of certain Muslim sects, and particularly the Su is [24]. Both these forms of contribution to psychotherapy were, in many ways, a type of introspection and self-understanding that resemble a psychoanalytical form of psychotherapy [23] or existential therapy that addresses the question of "What is the purpose of living?" and "Who am I ?" [22,23,25]. Al-Rawi and Fetters [26] recognized Salah and dhikr in their recent study for their therapeutic qualities, but does not discuss how such techniques can be implemented by modern Muslim clinicians. According to the primary sources of Islamic faith, regular and proper practice of prescribed Salah is a key parameter in assessing the quality of Islamic style of life of followers of Islam. Salah must be performed in all situations, where a believer might ind himself/herself: in peace and in war, on the road, at home, during the day, at night, on land, at sea, in the air, in sickness and health (provided that there are exemptions when not in normal situations) [18,27,28]. El-Azayem (1995) says that with irm bonding with Islamic principals human is able to prevail over feeling of depression, to strength will power and to support feeling of hope and optimism. Islam built such life concept that individual living in harmony and spirit of Islamic principals will absolutely be able to af irm him/herself as healthy, creative, balanced and human personality. In that regard very signi icant role belongs to prayer (Al-salah). Prayer neutralize emotional con licts, what is the best illustrated by life practice of Prophet Muhammad (peace be upon him) who, as tradition relates in conditions of sorrow and suffering, excitation or anxiety took refugee in the prayer. Islamic prayer extinguishes excitation or anxiety after it already has been happened.
"If you are in fear, or in dangerous, than pray your prayer…" (Qur'an, II, 239) In our clinical experience with traumatized clients and those who are suffering from PTSD, the policy of daily program of these religious activities can be applied in clinical purpose. That dependence from observation of prayers in its prescribed time in-group for all of those who are engaged in clinic and who practice religious obligations. Clients who are believers participate in it by themselves. We found out that after such sessions clients are less anxious, less depressive, they have better communications, symptoms of avoidance and hyper-arousal symptoms become decreased in its' intensity. But in perspective it could be better to be guided from Imam (Islamic minister), who is previous instructed in basic prepositions in psychotherapy and social therapy approach. After they inished prayer, clients go to continue work in group therapy of religious sessions where all team members collaborate. In such open sessions, therapeutic team, which is well trained in using religious faith as segment in whole therapy will give answers about religious obligations and its values in achieving effect of central nervous system wellness [11,15,28,] For this reasons we realized the 6 th Congress of World Islamic Association for Mental Health (1999) [29], two trauma courses for theologians, and several of them we included in group therapy education. Under our leaderships ive of them completed school of psycho-trauma in July 2000 that is organized every summer in Psycho-Trauma Center, Missouri University in Columbia, USA. At the end of 2001 we realized Seminar for ifty imams about Psychoactive substance abuse, after what we published book "Drug Dependency" published by Behram-.Bay's Madrasah and School of Medicine in Tuzla [30].

Therapeutic effects of group prayer (Jamaat) and its' Tranquilizing Infl uence
Sessions of group prayers provide spreading out of participants' interesting in their daily program, so it can teach them how to use their time in constructive and recreation activities which bring satisfaction and it is basement for behavior reconstruction in therapeutic purpose [31]. The role of Mosque is explained by its' using in previous described psychological determination. This can help in discovering of religion healing role. It brings light upon effect of patience and role of endorphins in pain removing and case stabilizing [32].
Religious (Islamic) community with the mosque in it's center exist with relatively stabile structures in majority of civil communities. As trauma is all-around, stabile communities like this can represent the irst line in protective response to trauma victims. Mental health experts could consider about incorporation of theologian structures in existing trauma response systems. Supportive and emphatic presence of these institutions can help in prevention for traumatized person not to draw in isolation, alienation or in deviation. Existing of such structure can facilitate rehabilitation from traumatic events, allowing to victims to notify that people are reachable in critical moments, to help, to take care or to console. Groups like these offer prolongation of social and spiritual support for severe trauma victims [1,3,15,[16][17][18]. There are some attempts to addressing theoretical models and Islamic-based interventions, but this need to be developed further to give clinicians solid tools to work with Muslim clients. A more expansive research is suggested including works in Muslim countries published in local languages [33].

Conclusions
There are strong evidences about that surviving intensive traumas can devastate human psyche and leave personality of traumatized in ruin, provided from psychiatrists and psychologists in existing scienti ic and professional literature. Wars, natural catastrophes and similar situations brings to survivors plenty of pain and sufferings, so that can lead to collapse of internal defense mechanisms and appearance of psychical complains that put normal life in disorder. Nowadays it is very important that professional helpers to trauma victims be ready to develop an integral and holistic model based on multidisciplinary including of all relevant resources in assessment and healing of psycho-trauma and PTSD consequences, because of modern level of human thought and eclectic approach, when all positive experiences in human practice are valuable.
Following up the needs of our psycho-traumatized clients in clinical treatment in postwar Bosnia and Herzegovina we found out that is very helpful to deal with spiritual issues in process of healing. From scienti ic research it is known that Islamic behavior principals are multiple bene icial when applied in every day life of believers, therefore using of daily Muslim routine incorporated in therapy facilitate process of healing of mental dysfunction. Focal role has Al-salah (Islamic obligated daily prayer) if it is practicing constantly either individually or in-group. To realize holistic approach in community based mental health care it is very important to educate religion professionals in psychotherapeutically approach, so they can be included as professional helpers in therapeutically team to be ready to meet sophisticated spiritual needs of traumatized believers. It can strongly help in process of spiritual healing of PTSD and different other mental disorders related with psycho-trauma. To build bridges, we have to be ready to cross over to the opposite banks, which don't give as con idence and security if we observe them from our side. Meanwhile when bridge is built up, it is easy to communicate for universal satisfaction.