Obsessive-Compulsive Disorder : Its What and How from an Islamic Perspective

Obsessive–Compulsive Disorder (OCD) is a type of anxiety in which a person suffers from obsessions i.e. unwanted intrusive ideas which recur to the person persistently; and compulsions i.e. behaviours that a person feels compelled to perform repeatedly in a ritualistic manner with the aim of relieving the anxiety from the unpleasant obsessive thoughts. Although compulsion and obsession are common, once the individual experiences excessive discomfort, then he or she would be diagnosed as a patient of this disorder. Most of the research outputs on this disorder are based on secular and irreligious perspectives. Thus, this research aims at religiously diagnosing its root causes and exploring its remedies based the Qur’an and Sunnah and the works of early Muslim scholars. The finding shows that this disorder, its etiology and treatment, has been extensively discussed in many works of early Muslim scholars that can be benefited by modern psychotherapists.


Introduction
Obsessive-Compulsive Disorder (OCD) is termed in Arabic as waswas.A person with OCD suffers from obsessions, that is, unwanted intrusive ideas and impulses which recur to the person persistently (Wehr, 1980).These obsessive thoughts compel him or her to perform repeatedly in a ritualistic and stereotyped manner with the aim of relieving or reducing the anxiety from the unpleasant obsessive thoughts.
Although obsession and compulsion are common for general population, once the individual experiences excessive discomfort and inability to carry on his or her daily routine, then he or she would be diagnosed as a patient of this disorder.Among common reported symptoms are obsessions of security (health and death), sexual acts, aggression and religious rituals like ablution (wudu'), physical purification (taharah), and prayers (solah).Researches on this disorder are normally based on cognitiveand behavioral perspectives that marginalize the role of religion and spirituality, especially the involvement of Satan as the source of evil whispers and faith (Iman) as its most effective defense mechanism Ibn Qayyim (1975).Thus, this research aims atholistically diagnosing its root causes and exploring its remedies based on the Qur'an and Sunnah and the works of early Muslim scholars.The discussion begins with the "what" of OCD from Islamic point of view where its definition and etiology or causes will be elaborated.This will be followed with the "how" of OCD that thoroughly looks at the comprehensive solution offered by Islam.

Definition of Obsessive-Compulsive Disorder (OCD)
In the works of early Muslim therapists, Obsessive-Compulsive Disorder (OCD) has been referred to as waswasah (pl.wasawis).This Arabic word refers to various kinds of concealed thoughts which are mostly evil by nature, such as doubt, devilish insinuation, temptation, and suspicion (Wehr, 1980).The use of this term by early Muslim scholars is indeed inspired by the Holy Qur'an that uses this word to refer to evil whispers of Satan as in the following first and second verses; and to the inner speech of the soul as in the last verse.Allah (s.w.t) says: "Then began Satan to whisper suggestions to them, in order to reveal to them their shame that was hidden from them before.He said, "Your Lord only forbade you this tree, Lest you should become angels or such being as live forever" 7:20).At another verse, Allah swt teaches men to seek protection "from the mischief of the whispers (of evil), who whispers into the hearts of mankind, among Jinn and among men" .The last verse cautions us on the potential that one's soul has in suggesting evils as Allah mentions, "It is We Who created man, and We know what dark suggestions his soul makes to him: for We are nearer to him than (his) jugular vein" (Al-Quran, 50:16).

The Etiology of OCD from an Islamic Perspective
Although OCD by definition refers to both obsessions and compulsions, early Muslim scholars have centered their discussions mostly on the etiology and treatment of obsessions rather than compulsions.They considered compulsions as simply a by-product of obsessions.Al-Bukhari, for example, discussed the etiology of obsessions and then explained how they negatively influence human behaviours.Another early Muslim scholar, Ibn Qayyim (1975) in his Ighathah al-Lahfan min Masyayidial-Shaytan deliberated the roles of waswasah or persistent thoughts of doubt in affecting a Muslim performing Islamic rituals like ablution (wudu'), physical purification (taharah), and prayers (solat).
It is of interest to note that early Muslim physicians and therapists have perceived obsessions as a continuum, that is, they are gradual in severity.They first speak about the normal forms of obsessions that can afflict a normal person.These are mild and do not impair his or her capacity to engage in useful activities.The person can simply divert his or her attention from these intrusive thoughts.As for OCD as a disorder, by reading through many of their works, it will be found that they specified three major contributing factors: namely inner-biological, cognitive and spiritual factors.With regards to the internal biological factors, Al-Bukhari in his Masalih said that the disturbance in some humours may give rise to an obsessive temperament due to which a person begins to get obsessive thoughts.Though the ancient biological theory of body humours is no more accepted, the description of Al-Bukhari's temperamental predisposition is quite similar to the modern classification of obsessional personalities.It is because like a personality trait, a temperament signifies an inherent component of the human disposition which is rather permanent.Accordingly, Al-Bukhari was indeed referring to what is termed today as obsessive personality (Asif, 2003).
With regards to the second psychological factor, early Muslim scholars seem to have a unanimous view that the underlying cause of most OCD cases is faulty and negative thoughts.This is because they believed that all voluntary actions develop from khawatir or fast, inner, concealed reflections, notion or subvocal thoughts that may come momentarily or fleetingly.A faulty and negative inner thought later develops to conscious thinking.This thinking will be transferred to or stored in the memory, and later transformed into a motive.The motive is then carried out in real life in the form of an action.The action that is repetitively done would turn to be a habit.From this, it was deduced that negative repetitive thoughts could develop from mere reflections to obsessional motivating habits that lead to compulsive actions.Ibn Qayyim (1992) in his al-Fawa'id writes about these developmental stages of khawatir in the following translation: You should know that the beginning of any voluntary act is concealed reflection (khawatir) and concealed whisper (waswasah (pl.wasawis)).These khawatir and wasawis lead to conscious thinking.
Next, thinking will be transferred to or stored in the memory and the memory will transform it into volition and a motive which will be acted out in real life as an action.Repeating the action leads to a strong habit." From the spiritual perspective, al-Ghazali (1982) refers to the same aspect of fleeting thought but he attributes them to either the inspiration from Angel or the works of Satan.These thoughts according to him can either be praiseworthy (mahmud) or blameworthy (mazmum).They are praiseworthy when they call for good and become blameworthy when they call for evil or harm.The one which is praiseworthy is called ilham (inspiration), while the blameworthy one is called waswas (evil whisper).The question may arise as to what makes these khawatir praiseworthy or blameworthy.According to al-Ghazali, the source of blameworthy thoughts is Satan, while the source of praiseworthy thoughts is the Angel.Al-Ghazali went further in explaining what he means by Angel and Satan.Angel is a creation of God who is entrusted with good and knowledge.He is responsible for unveiling the truth, giving good promise, and promoting the good.On the other hand, Satan functions as the one who promises evil and promotes vile and harmful deeds.
One of the things that Satan whispers into human minds is excessive and pathological doubt, and this doubt is the basis of most cases of OCD (Ibn Qayyim, 1975).The person who is overly concerned about his health will be in a constant state of worry about it and thus will take any possible precaution to preserve his health.Any peculiar bodily symptoms will be considered as an illness, while any mild illness will be exaggerated.This feeling of being overly concerned with health will be used by Satan to deviate the person from the right path.By whispering to the heart of the person, Satan cultivates the feeling of dissatisfaction and doubt about the effectiveness of the precautious measure taken by the person to secure his health.This can be seen clearly in the case of the compulsion of persistent hand washing.The patient washes his hands repeatedly until they develop sores.After accomplishing each wash, the person will experience the feeling of relief from anxiety.Doubt is indeed an anxietyprovoking agent while the act of washing is reinforced with the feeling of relief from anxiety.These two elements are strong enough to ensure the continuity of the act.
With regards to repetitive checking, this also springs from the feeling of doubt which is whispered by Satan into the mind of the person.This doubt afflicts patients who are overly concerned about the safety of their property and wealth.Again, after each and every checking, the person is rewarded with the feeling of relief from anxiety.After some time, the feeling of doubt comes again and the same reinforced move will be acted out.Being in doubt about the cleanliness of the physical body and about the security of our belongings will inspire us to take certain normal actions, namely washing and checking.However, as al-Ghazali (1982) says, Satan manipulates these normal and constructive feelings to extreme doubt and obsessions.According to al-Ghazali, besides distinctly good (ilham) and evil obsessions (waswas), there are obsessions that are vague and indistinct.These vague and indistinct obsessions are the ones used by Satan to initiate obsessional behaviours.
According to modern Western psychotherapists, one of the characteristics of OCD is that the person inflicted knows about the irrationality of his act, but he cannot resist it (Maxmen, 1986).This feeling of "cannot resist" or 'irresistible" is indeed an exaggeration.It may result from the deterministic view of human nature as perceived by psychoanalysis and behaviorism.However, this deterministic view of human nature cannot be accepted from an Islamic point of view, since there is no such thing in human minds and their behavioursthat are irresistible and cannot be changed.The proper expression might be "hard" or "difficult" or "unpleasant" to resist and to change.It indeed depends on the outcome of theconstant struggle with alternate success between the reason ('aql) and desire (hawa) that takes place in the heart.The degrees of difficulty are subject to the degrees of influence and authority that Satan and desire (hawa) have on one'sheart that makes him feel almost impossible to resist the whisper of Satan, although he knows that he is not acting as he should in resisting the suggestion.Due to this, one will claim that his character is immutable and cannot be altered (al-Ghazali, 1982).However, if the heart of the person is under the control of the reason ('aql), the person would optimistically resist his intrusive thoughts and fight them with his spiritual motivation.For this reason, Ibn Qayyim in his Ighathah (1975) has strongly condemned those obsessive people for accepting and believing these false and irrational thoughts and held them responsible for their condition.This constant struggle between the reason ('aql) and desire (hawa) that takes place in the heart is a deeply rooted aspect of Islamic psychology.Since the heart is the one that controls the organs of the body, authority goes to whichever of the two parties overpowers the heart.If the heart is overpowered by reason, its affairs will be good and consequently the organs of the body will function well.On the other hand, if the heart is overpowered by desire, it will be corrupted and its affairs will be incorrect, and consequently the organs will be in a state of malfunction.This is stated very lucidly in a well-known tradition of the Prophet (pbuh), " Beware!There is a piece of flesh in the body.If it is healthy, the whole body is healthy.If it becomes unhealthy, the whole body gets unhealthy -that is the heart" (authenticated by al-Bukhari in his Sahih).Al-Bukhari. (n.d.).
Most of psycho-spiritual malfunction such as OCD, excessive anxiety and depression are caused by its sickness.This significance of the heart is mentioned in many places in the Holy Qur'an.In some of its verses, the Qur'an certifies that there are diseases in the hearts of the Hypocrites, "In their heart is a disease" (Al-Quran, 2:10).In other places, Allah describes the diseased hearts as the ones which are being sealed, wrapped and locked, "Allah hath sealed their hearts; so they know not" (Al-Quran, 9:93), that their "hearts are enwrapped"(Quran, 2:88).Upon apprehending the above mentioned verses, we come to know beyond all doubt that the heart is the causation of psycho-spiritual illnesses including OCD.In relation to the heart, faith (Iman) is its most effective defense mechanism and protection from OCD and other psycho-spiritual illnesses.Faith increases with the increase of knowledge of God and the fulfillment of all commands, and avoidance of all prohibitions.The illness of the heart is due to the void or dispossession of the light of faith.This is so because the heart is being stained and covered with the dirt and pollution of the desire (hawa).The winning of the desire over the reason is the starting point of man's psycho-spiritual problems.This is due to the light of Iman within the heart becomes weaker and eventually becomes lost.The desire will conquer and control the heart and give no chance to reason to function properly.The heart will be filled with evil virtues such as doubt, greed, excessive love towards this world and so on.On top of that, the desire indeed enslaves the reason for its evil interests.Since the lack of Iman is the major cause of OCD that succumbs a person to doubt and faulty thought, the right and proper treatment, therefore, must be centered on restoring and increasing it.

Treatment of Obsessive-Compulsive Disorder
After having understood the nature of OCD and its etiology, it is now time to discuss its treatments from an Islamic perspective.We have already delineated that the main and predominant cause of OCD is directly and indirectly related to the lack of Iman.Consequently, the lack of Iman leads Muslims to develop doubt, false and negative beliefs in their minds.These beliefs, as identified by early Muslim scholars, are related to their conception about the nature of God, about human nature, and about this world and the Hereafter.Therefore, in order to have an effective cure for OCD, modern Muslim psychologists and psychotherapists should seriously take these matters into consideration.Now, let us delineate one of the major treatments that had been discussed and applied by early Muslim scholars to treat OCD.This treatment or therapy is known as Iman Restoration Therapy (IRT).
This process of restoring and increasing Iman is not as simple as filling and increasing water in a glass.This is because Iman is not merely a vain wish but it is that which is established in the heart and verified with works (Ibn Majah, n.d.),The establishment in the heart requires proper and true knowledge while the verification with works requires inner struggle (mujahadah) and discipline (riyadah).Hence, there are two essential elements in the Iman Restoration Therapy (IRT), namely instilling into the heart with true and certain knowledge and conditioning it with inner struggle and discipline.

Knowledge Instilment
Because the abode of Iman is the heart, early Muslim scholars believed that any defect in Iman must be due to the spiritual illness of the heart (al-Kalabazi, 1969).The most dangerous disease that afflicts the heart is the disease of ignorance.It is because of ignorance that a person tends to have all those doubts, false beliefs and confusions.Like the physical body that has weak immunity that can easily succumb to diseases, the heart with weak spiritual immunity too can be easily 'infected' and misdirected.In order to strengthen the immunity of the body, a person needs to take specific antibodies, drugs or good nourishment; for the heart, the best immunization is by instilling true and certain knowledge (yaqin).Knowledge about these four main aspects of the Islamic worldview, as al-Ghazali (2000) says, is therapeutic and that ignorance is a deadly poison for the heart.To give an effective help to their patients with OCD, modern Muslim therapists need to make use of these four aspects in diagnosing and treating their Muslim clients.
Examining their thought processes of Muslim patients and correcting their doubtful and faulty thoughts are what we refer to today as cognitive psychotherapy.When it is based on religious and spiritual aspects, it will be cognitive psychospiritual therapy.
Al-Ghazali in his Ihya (1982), pointed out the significance of this knowledge in the treatment of OCD.He says that it is our duty to verify each and every khatir that penetrates our hearts whether it is ilham or waswas of Satan.For this purpose of verification, one must equip oneself with knowledge, namely the knowledge that brings one to taqwa and the knowledge that unveils the trickery of Satan.Without this knowledge, it is difficult for a person to get rid of his problem.Al-Ghazali goes on to say that there are many doors for Satan to enter the heart, compared to only one door for ilham.Furthermore, this one door gets mingled with those other doors so much so that one is hardly able to distinguish among them.It is like a traveler who is stranded in a desert which has many roads without clear directions in a dark night.It is hard therefore to know the right direction except with the inner acute eye of discernment ('ainbasirah), and the sunlight of knowledge.The eye of discernment here refers to a heart which is pure with piety (taqwa), while the sunlight refers to various ample knowledge which is derived from the Al-Quran, and traditions of the Prophet (pbuh).By this knowledge, one can produce and nourish certainty (yaqin) and healthy thoughts as an emergency aid for unexpected emotional outburst.After having the knowledge, one is able to give all the right and proper answers and solutions to the problems he faces in life.This knowledge will bestow him with the ability to think rationally and positively, eliminating the irrational and faulty thoughts that cause OCD.His reason will be able to analyze and test any incoming thoughts.It is comparable to the conscientious and well-trained security guard who allows no one to trespass without proper and conscientious scrutiny.In modern information and communication technology, it is comparable to a very good antivirus that scans all incoming information to a system or a computer.As antivirus needs to be regularly updated, one's knowledge also supposedly needs to be updated and increased.Thus, any detected negative thought which is indeed the cause of OCD and other psycho-spiritual diseases will be negated while the positive ones will be welcomed.Such healthy thoughts and cognitions, according to Al-Bukhari (1984), should be initiated and stored in the memory when a person is in a tranquil and relaxed condition.
All the examples of positive thoughts that are cited by Al-Bukhari are indeed the outcomes of having true knowledge and conceptions of those four fundamental issues that we have already mentioned.For example, Allah (s.w.t) is the creator of all things, and that for each and every illness, there is a cure except that of being old and death.Al-Balkh (1984) has repeated about these realities many times throughout the section on OCD.His stress on this matter is justified because the majority of individuals inflicted with OCD, are those who forget or are unaware of these realities.Another early Muslim scholar, Miskawayh in his Tahzeb shows how this knowledge can be used to treat patients with the obsessions of death.According to him, this feeling arises due to false thinking resulting from ignorance.Thus, he proposes a cognitive approach for the treatment to these false thoughts.He says that these negative thoughts should be confronted and rationalized, in particular a person whose obsession over death is due to relatives or descendants, as well as wealth that he will have to leave behind, and who regrets to leave behind the delights and desires of this world.Miskawayh (n.d.) showed in a convincing manner the irrationality of this kind of thought when he says: "... such a person must be told clearly that anxiety over the anticipation of a pain or an evil brings no benefit whatsoever.(He must know) that man is one of the generables (ka`inat)....It is clear that every generable is inevitably corruptible.Thus, he who wishes not to suffer corruption also necessarily wishes not to be, and he who wishes not to be also necessarily wishes for his own corruption.It is as if he wishes (both) to suffer corruption and not to suffer corruption, to exist and not to exist.This is impossible and would not occur to the mind of an intelligent person." In supporting his logical argument, Miskawayh (n.d.) came up with a simple but very significant example.He made his client to rationalize death as a divine mechanism that maintains the approximate number of human beings in this world.In other causes of obsession over death, such as the belief that death involves a great pain other than the pain of the diseases which may have preceded and caused it, or the unknown ultimate destiny of his soul and the nature of the life to come that he will face, Miskawayh again attributed their causes to ignorance.Thus, the remedy for such illness is knowledge and doing good deeds.These are some examples on how true knowledge and conceptions can help a person to get rid of OCD.With this knowledge as part of their expertise, Muslim therapists have rich resources to carry out effective treatment to clients with OCD.What they use in their cognitive healings is the Truth that patients have faith in, and not merely superficial conjecture.Besides providing the patient with this knowledge which is the first phase of Iman restoration therapy, the treatment of OCD will be more effective if the patient proceeds to the second phase which is inner struggle and discipline.

Inner Struggle (Mujahadah) and Discipline (Riyadah)
In Islamic psycho-spiritual therapy, we have two very important and indispensable methods in the treatment of OCD and other psychospiritual disorders.These are known as inner struggle (mujahadah) and discipline (riyadah).For example, Al-Razi (1950), an early Muslim scholar and physician, regards gradual training of the soul in suppressing the passions and opposing their natural inclinations to be the most important aspect of treatment in psychospiritual illnesses.He then compares them to the medicines that are used to treat physical illnesses.He says that in treating the body we use medicines, however, the medicines of the soul come through inner struggle (mujahadah), discipline (riyadah).These two terms mujahadah and riyadah have slightly different meanings but they are related like the two sides of the same coin.The former refers to an individual's struggle against his animalistic soul to prevent him from indulging in Islamically forbidden desires (shahwah), and the other, discipline or riyadah, refers to acquiring good habits which secure the pleasure of God (al-Ghazali, 1982) These methods are very effective in treating the root cause of OCD which is mostly due to the illness of the soul or heart.

Inner Struggle (Mujahadah)
It is interesting to point out that healing by the opposite or as is termed today, reciprocal inhibition, is in fact the essence of inner struggle.Itis to "wean the soul from its habits and compel it to oppose its passions at all times" (al-Qusyairi, n.d.)In order to understand this statement, we have to understand the nature and reality of the soul.A healthy soul is the soul which is in a state of equilibrium.By the state of equilibrium here, we mean a balanced state of the functioning of the faculties of the soul, namely the faculty of desire (al-quwwah al-shahwaniyyah), the faculty of anger (alquwwah al-ghalabiyyah) and the reason('aql).To be balanced, all these faculties must be in a correct proportion to each other, in which the desire submits to the reason.
The soul which is in this state will produce good characters such as patience, love of knowledge, wisdom and many others.All these qualities are the necessary elements in the treatments of OCD.Generosity prevents from the excessive love of wealth and material possessions.This excessive love causes a person to have constant obsession of the possibility of losing his property.Patience prevents a person from being afflicted with excessive anger and severe depression.Without these two maladaptive emotional reactions, the person will be able to have proper and rational thinking and tranquil emotionality.He will not be enslaved by negative and irrational thoughts that lead to obsession.Love of knowledge and wisdom is ultimately necessary because ignorance, as we have already stated, is the true underlying cause of OCD.
On the other hand, the soul which is not in a state of equilibrium will produce blameworthy characters such as greed and excessive love of wealth, impatience, anger, less interest to acquire knowledge and wisdom.All these qualities bring about obsession and other psycho-spiritual illnesses.Therefore, in order to get rid of obsession, this equilibrium must be maintained.In order to maintain it, one has to constrain the soul from being led by its base desires.This principle, according to al-Ghazali (1982), is quite similar to the principle of treatment for bodily illness.The body which becomes sick due to lack of the equilibrium of humours may only be cured through the opposite.If it proceeds, for example, from heat then the treatment should be with something cool, and vice versa.Therefore, with respect to the soul, the disease of ignorance (jahl) is treated by learning (ta'allum), that of doubt by certainty (yaqin),and that of impatience by forcibly restraining oneself from quick and immature thinking.Thus to accomplish this task, it requires a person to endure the unending struggle against one's desire until he gains mastery over it.According to al-Ghazali, the mastery of reason upon the desire will keep Satan which is the source of evil obsessions away from the heart.In this state, Satan will lose its sustenance, that is, desire.Without it, Satan will have no place of attraction in human psyche.Al-Ghazali gave a good analogy concerning this matter.He compared the heart to a house that becomes the aim of a thief because of what it has.However, if it has nothing attractive to the thief, he will leave it.Allah says in the Holy Qur'an, "As for My servants, no authority shalt thou (Satans) have over them."(Al-Quran, 17:65).

Discipline (RiyaÌah)
In due course, the patient needs to discipline his soul towards acquiring good habits which secure the pleasure of God.This gradual process of cultivating good traits and to make an established habit is what is known as self-discipline or riyadah al-nafs.The word "riyadah" is derived from an Arabic word "rawada" which has the meaning of "to tame, to train, and to domesticate" in a way which generatesdocility, tractability, and gentleness (Abdullah, 1989).The soul is accustomed to enjoyment and desire.It has to be tamed and trained by cutting it off eventually from its customs and replacing them with good traits.Therefore, we may say that discipline (riyadah) simply means the process by which the soul is gradually trained to cultivate good traits.For example, a person who is too obsessed with this worldly life and forgets God has to train and discipline himself with ibadah (acts of service to God) and zikr Allah (remembrance of God) that will bring him nearer to God.It is clear therefore that inner struggle and discipline are not only necessary, but also very effective in changing one's blameworthy behaviours to praiseworthy ones.In summary, through the process of seeking knowledge, inner struggle and discipline, one will be able to reilluminate the heart with the light of faith that will rid one from obsession and other psycho-spiritual illnesses.

Conclusion
In conclusion, this overall perspective of OCD, that is its "what" and "how" is the true reflection of Islam which is characterized by comprehensiveness (al-shumul).This is reflected in ImanRestoration Therapy (IRT) that integrates cognitive, emotive, spiritual and behavioral approaches.It functions by reilluminating the heart with the light of faith that will removea person from doubt and faulty thoughts which are the source of OCD.With knowledge, a person will arrive at certainty and by continuous inner struggle (mujahadah) and discipline (riyadah), he or she will gradually transform himself or herself to be a true believer (mu'min) which is free from obsessional neurosis.He or she will enjoy complete tranquility (tuma'ninah) and happiness (sa'idah) and be strong in facing all the psychological illnesses like OCD.Realizing this comprehensive and effective solution offered by religion especially Islam, it is no wonder that lately many secular psychologists and psychotherapists have started to adopt parts of religious teachings and practices into their psychotherapeutic practices.They know that by totally rejecting religion and spirituality, they would not be able to provide a good and effective cure to their patients.
Based on this principle, early Muslim scholars like al-Ghazali in Mizan al-'Amal on the chapter of Mudawat al-Ghamm (1989); Miskawayh in Tahzib al-Akhlak on the chapter of 'Ihya al-Huzn (n.d.); and Al-Bukhari in Masalih on the chapter of Tarbiyyat al-Nafs (1984) have urged Muslims to have sufficient knowledge about four fundamental issues, namely God, human nature, this world, and the Hereafter.